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Jefferson FA, Linder BJ. Hemorrhagic Cystitis: Making Rapid and Shrewd Clinical and Surgical Decisions for Improving Patient Outcomes. Res Rep Urol 2023; 15:291-303. [PMID: 37404838 PMCID: PMC10317550 DOI: 10.2147/rru.s320684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
Hemorrhagic cystitis (HC) can be one of the most challenging clinical scenarios for urologists to manage. It most commonly occurs as a toxicity of pelvic radiation therapy or in patients treated with the oxazaphosphorine class of chemotherapy. Successful management of HC necessitates a stepwise approach with a thorough understanding of the various treatment options. Once ensuring hemodynamic stability, conservative management includes establishing bladder drainage, manual clot evacuation, and continuous bladder irrigation through a large-bore urethral catheter. If gross hematuria persists, operative cystoscopy with bladder clot evacuation is often required. There are multiple intravesical options for treating HC, including alum, aminocaproic acid, prostaglandins, silver nitrate, and formalin. Formalin is an intravesical option that has caustic effects on the bladder mucosa and is most often reserved as a last-line intravesical treatment. Non-intravesical management tools include hyperbaric oxygen therapy and oral pentosan polysulfate. If needed, nephrostomy tube placement or superselective angioembolization of the anterior division of the internal iliac artery can be performed. Finally, cystectomy with urinary diversion is a definitive, albeit invasive, treatment option for refractory HC. While there is no standardized algorithm, treatment modalities typically progress from less to more invasive. Clinical judgement and shared decision-making with the patient are required when choosing therapies for managing HC, as success rates are variable and some treatments may have significant or irreversible effects.
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Ziegelmann MJ, Boorjian SA, Joyce DD, Montgomery BD, Linder BJ. Intravesical formalin for hemorrhagic cystitis: A contemporary cohort. Can Urol Assoc J 2017; 11:E79-E82. [PMID: 28360951 DOI: 10.5489/cuaj.4047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hemorrhagic cystitis presents a difficult clinical challenge, yet data regarding treatment options is sparse. Here, we sought to evaluate outcomes of a contemporary cohort of patients treated with intravesical formalin for hemorrhagic cystitis. METHODS We identified a retrospective cohort of eight patients managed with formalin for hemorrhagic cystitis from 2000-2014. All patients failed prior measures, including bladder irrigation, clot evacuation, and other intravesical agents. Treatment success was defined as hematuria resolution during the given hospitalization without use of additional invasive therapies. We also evaluated treatment complications and additional treatments following hospital dismissal. RESULTS Etiology of cystitis was radiation for malignancy in all cases. The formalin concentration ranged from 1-4%, with escalation used in treatment failures. Five patients (62.5%) received a single dose of 1% formalin, two patients received two doses, and one patient received three doses. Notably, intraoperative cystography identified vesicoureteral reflux (VUR) in 50.0% of patients. Six patients (75.0%) achieved treatment success, with a median time to resolution of four days (range 1-17 days). Of those refractory to formalin, one was managed with indwelling nephrostomy tubes and one underwent cystectomy. Median followup was eight months. Of the responders, two eventually required cystectomy, one for recurrent hematuria and one for recalcitrant bladder neck contracture and bladder dysfunction. The remaining four patients (50%) required no additional therapy. CONCLUSIONS Formalin remains an important tool for treating refractory hemorrhagic cystitis, with roughly 75.0% of patients requiring no additional therapy prior to hospital discharge. Notably, there is a risk of bladder dysfunction following formalin.
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Affiliation(s)
| | | | - Daniel D Joyce
- Department of Urology, Mayo Clinic, Rochester, MN, United States
| | | | - Brian J Linder
- Department of Urology, Mayo Clinic, Rochester, MN, United States
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Mallick S, Madan R, Julka PK, Rath GK. Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management. Asian Pac J Cancer Prev 2015; 16:5589-94. [DOI: 10.7314/apjcp.2015.16.14.5589] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
PURPOSE OF REVIEW To better understand the mechanism of radiation-induced hemorrhagic cystitis and the advantages and disadvantages of available treatment options for bladder hemorrhage as well as preventive measures. RECENT FINDINGS There have been several attempts recently to manage hemorrhagic cystitis with hyperbaric oxygen therapy, transurethral coagulation using Greenlight potassium-titanyl-phosphate laser and other different treatment modalities, but we still need more investigation on larger cohort studies. SUMMARY Hemorrhagic cystitis is an uncommon urological problem. It is most often caused by radiation therapy and cyclophosphamide, but can be associated with other contributing factors. Technological advances in radiation therapy have resulted in greater treatment efficacy, with significant reduction in side-effects such as hemorrhagic cystitis. Higher dose radiation treatment, however, is more often associated with problematic hemorrhagic cystitis. Treatment of hemorrhagic cystitis is multifactorial and can range from simple bladder irrigation to cystectomy with urinary diversion.
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Abt D, Bywater M, Engeler DS, Schmid HP. Therapeutic options for intractable hematuria in advanced bladder cancer. Int J Urol 2013; 20:651-60. [PMID: 23387805 DOI: 10.1111/iju.12113] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 01/14/2013] [Indexed: 11/30/2022]
Abstract
Intractable hematuria is a common and severe complication in patients with inoperable bladder carcinoma. The aim was to provide an overview of therapeutic options for such cases, and analyze their effectiveness and risk profile, so a systematic literature search of peer-reviewed papers published up to September 2012 was carried out. Various options are available to treat hematuria in patients with inoperable bladder cancer; these include orally administered epsilon-aminocaproic acid, intravesical formalin, alum or prostaglandin irrigation, hydrostatic pressure, urinary diversion, radiotherapy, embolization and intraarterial mitoxantrone perfusion. These treatment options are associated with different prospects of success, risks and side-effects. Well-designed and large studies comparing options are completely lacking. Despite various treatment options, management of intractable hematuria in patients with inoperable bladder cancer remains a challenge, and most of the reported methods should be seen as experimental. Interventional radiology and alum instillation seem to be suitable alternative options for patients who, after critical consideration, cannot be treated by irrigation, transurethral resection or palliative cystectomy.
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Affiliation(s)
- Dominik Abt
- Department of Urology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland.
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Martínez-Rodríguez R, Areal Calama J, Buisan Rueda O, González Satue C, Sanchez Macias J, Arzoz Fabregas M, Gago Ramos J, Bayona Arenas S, Ibarz Servio L, Saladié Roig J. Practical treatment approach of radiation induced cystitis. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s2173-5786(10)70148-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Decker DB, Karam JA, Wilcox DT. Pediatric hemorrhagic cystitis. J Pediatr Urol 2009; 5:254-64. [PMID: 19303365 DOI: 10.1016/j.jpurol.2009.02.199] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 02/13/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE To review the current literature as it pertains to hemorrhagic cystitis (HC) in the pediatric bone-marrow transplant (BMT) population. By reviewing the pathophysiology of the disease, preventive methods, and therapeutic options, urologists may be better equipped to manage this challenging clinical scenario. MATERIALS AND METHODS The HC literature was reviewed using a MEDLINE/PubMed literature search, specifically focusing on the pediatric BMT population as it pertains to the incidence, pathophysiology, prevention, and treatment of HC. RESULTS Conservative estimates of HC incidence in recent retrospective studies of pediatric BMT populations still approach 10-20%. Several high-volume pediatric BMT centers have reported contemporary data on their experience with HC providing increased insight into incidence and pathophysiology. Accumulating evidence linking BK virus to HC is a significant development warranting further investigation. Other contributing agents/risk factors need identification in the likely multifactorial etiology of HC. Preventive and therapeutic strategies have made modest advances, but certainly need further validation with prospective randomized studies. CONCLUSIONS Pediatric BMT patients are susceptible for HC development despite preventive measures and improved insight into the pathophysiology. Unfortunately, there are no evidence-based treatment guidelines for this difficult clinical issue that frequently requires prolonged care and multiple treatment modalities necessitating judicious patience in the application of more aggressive interventions.
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Affiliation(s)
- Daniel B Decker
- Children's Medical Center at Dallas, University of Texas Southwestern Medical Center, Department of Urology, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA.
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Rastinehad AR, Ost MC, VanderBrink BA, Siegel DN, Kavoussi LR. Persistent prostatic hematuria. ACTA ACUST UNITED AC 2008; 5:159-65. [DOI: 10.1038/ncpuro1044] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Accepted: 12/10/2007] [Indexed: 11/09/2022]
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Maduro JH, Pras E, Willemse PHB, de Vries EGE. Acute and long-term toxicity following radiotherapy alone or in combination with chemotherapy for locally advanced cervical cancer. Cancer Treat Rev 2003; 29:471-88. [PMID: 14585258 DOI: 10.1016/s0305-7372(03)00117-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Randomised studies in locally advanced cervical cancer patients showed that cisplatin should be given concurrently with radiotherapy, because of a better long-term survival compared to radiotherapy alone. This increases the relevance of treatment related toxicity. This review summarises the acute and long-term toxicity of radiotherapy given with or without chemotherapy for cervical cancer. Acute toxicity (all grades) of radiotherapy is reported in 61% of the patients in the rectosigmoid, in 27% as urological, in 27% as skin and in 20% as gynaecological toxicity. Moderate and severe morbidity consists of 5% to 7% gastrointestinal and 1% to 4% genitourinary toxicity. Adding chemotherapy to radiotherapy increases acute haematological toxicity to 5% to 37% of the patients and nausea and vomiting in 12% to 14%. Late effects of radiotherapy include gastrointestinal, urological, female reproductive tract, skeletal and vascular toxicity, secondary malignancies and quality of life issues. For at least 20 years after treatment, new side effects may develop. Gastrointestinal toxicity usually occurs in the first 2 years after treatment in about 10% of the patients. The incidence of moderate and severe urological toxicity can increase up to 10% and rises over time. Gynaecological toxicity usually occurs shortly after treatment while skeletal and vascular toxicity can occur years to decades later. Thus far, no increase in late toxicity has been observed after the addition of cisplatin to radiotherapy. Finally, methods to prevent or decrease late toxicity and therapeutical options are discussed. However, most randomised studies still have a limited follow-up period.
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Affiliation(s)
- J H Maduro
- Department of Radiotherapy, University Hospital Groningen, Groningen, The Netherlands
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García Ligero J, Mora Peris B, García García F, Navas Pastor J, Tomás Ros M, Sempere Gutiérrez A, Rico Galiano JL, Fontana Compiano LO. [Hemorrhagic cystitis caused by BK and JC polyomavirus in patients treated with bone marrow transplantation: clinical features and urologic management]. Actas Urol Esp 2002; 26:104-10. [PMID: 11989422 DOI: 10.1016/s0210-4806(02)72741-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Differential diagnosis of hematuria after bone marrow transplantation (B.M.T.) may include polyomavirus (BK and JC)-associated haemorrhagic cystitis. Many reports have implied BK virus as the major pathogen in the development of hemorrhagic cystitis after BMT. BK viruria is also associated with ureteric stenosis in renal allografts recipients. Viral urinary tract infections are uncommon in healthy individuals, but we can find them frequently in patients under immunosuppressive conditions. MATERIAL AND METHODS Retrospective study of 123 consecutive B.M.T. recipients in the period from 1995 to 2000, evaluating those with polyomavirus-associated hemorrhagic cystitis. We present patient's characteristics, primary disease, clinical features, diagnosis aspects and treatment of these "hidden hosts of urinary tract". RESULTS 7 patients (5.7% of B.M.T.) developed BK or JC virus-associated hemorrhagic cystitis; 3 men and 4 women; median patient age was 29 years (range 14 to 45 years). Bacterial, mycobacterial and parasitic urine cultivates had negative results in all of them. The clinical course was characterized by a late onset of haemorrhagic cystitis (days +30 to +132 after BMT). All 7 patients developed macroscopic haematuria (duration 3 to 30 days). In 6 cases Graft Versus Host Disease (G.V.H.D.) criteria were found. Ultrasonographic studies revealed diffuse thickening of bladder wall in 5 patients. Hematuria was managed by hyperhydratation, blood transfusions, transurethral catheter and evacuation of blood clots, continuous bladder irrigation, urine alkalinization and antiviral therapy. No other more aggressive measures were required to stop the bleeding. Only 1 case of transient elevated creatinine. CONCLUSIONS Polyomavirus-associated haemorrhagic cystitis must be considered in differential diagnosis of hematuria in bone marrow transplantation recipients. Urological management, according with the severity and duration of hematuria, is frequently required.
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Affiliation(s)
- J García Ligero
- Servicio de Urología, Hospital General Universitario de Murcia
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Affiliation(s)
- S K Choong
- St. George's Hospital, Blackshaw Road, London, UK.
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Suzuki K, Kurokawa K, Suzuki T, Okazaki H, Otake N, Imai K, Yamanaka H. Successful treatment of radiation cystitis with hyperbaric oxygen therapy: resolution of bleeding event and changes of histopathological findings of the bladder mucosa. Int Urol Nephrol 1998; 30:267-71. [PMID: 9696331 DOI: 10.1007/bf02550308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To assess the effect of hyperbaric oxygen (HBO) therapy on radiation cystitis, clinical and histopathological characteristics were examined. Three women with radiation cystitis were treated with HBO therapy. Macrohaematuria was arrested in all patients. Cystoscopy demonstrated abnormal telangiectasia and inflammatory mucosa before treatment. After HBO therapy, the inflammatory mucosae were healed. However, abnormal vessels did not completely disappear. Histopathologically, the epithelium was atrophic and dilated lymph vessels and inflammatory cells were seen in the submucosa. These changes improved after treatment. HBO therapy is effective against radiation cystitis. With improvement of the clinical symptoms also the cystoscopic and histopathological findings changed favourably.
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Affiliation(s)
- K Suzuki
- Department of Urology, Gunma University School of Medicine, Maebashi, Japan
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Giannakopoulos X, Grammeniatis E, Chambilomatis P, Baltogiannis D. Massive haemorrhage of inoperable bladder carcinomas: treatment by intravesical formalin solution. Int Urol Nephrol 1997; 29:33-8. [PMID: 9203035 DOI: 10.1007/bf02551414] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Numerous modalities of treatment have been used in the past to control massive bladder haematuria, with varying degrees of success. Formalin has been used in urology only for the treatment of intractable haematuria of inoperable bladder carcinomas, usually as the last resort when all other nonsurgical attempts have failed and before more aggressive surgical measures are considered. Eight patients with bladder tumours classified T2 (2 cases), T3 (2 cases) or T4 (4 cases) and 2 patients with radiation cystitis were assessed as being beyond the scope of even palliative surgery, severe haemorrhage being present in all cases. The treatment was instituted in all cases by intravesical instillation of a 10 per cent formalin solution under general anaesthesia. Four patients received 4 and 6 instillations, respectively, the former over 4 weeks and the latter over 10 months. The bladder was filled completely and an indwelling-catheter introduced, the formalin solution being left in the bladder for 5 to 30 min (mean: 12 min). Haematuria was absent after 1 to 25 days (mean: 11 days) in 9 cases. The 10th patient died before arrest of haemorrhage. Survival after instillation was 65 days to 27 months (mean: 11.5 months). The outcome was fatal within 4 months or less in 3 cases and 4 patients died of renal failure within 3 months, one within 65 days after instillation. In 4 cases, treatment with formalin reduced bladder capacity to less than 100 ml. Other complications included retroperitoneal fibrosis (1 case), urinary incontinence (3 cases) and severe frequency and nocturia (3 cases). This procedure should therefore be reserved for terminal cases unable to support more aggressive therapy.
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Affiliation(s)
- X Giannakopoulos
- Department of Urology, Ioannina University School of Medicine, University Hospital, Greece
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Ippoliti C, Przepiorka D, Mehra R, Neumann J, Wood J, Claxton D, Gajewski J, Khouri I, van Besien K, Andersson B. Intravesicular carboprost for the treatment of hemorrhagic cystitis after marrow transplantation. Urology 1995; 46:811-5. [PMID: 7502421 DOI: 10.1016/s0090-4295(99)80349-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To determine the minimal active dose and extent of activity of intravesicular carboprost for the treatment of hemorrhagic cystitis after marrow transplantation. METHODS Twenty-four adults with grade 3 or 4 hemorrhagic cystitis were treated. All but 2 had failed other local therapy. Treatment was initiated at a median of 32 days post-transplant. Eleven patients received carboprost intravesicularly at 0.2 mg/dL for 60 minutes every 6 hours, and the dose was escalated every 24 hours until a dose of 1.0 mg/dL was reached unless a response was achieved. Thirteen additional patients were treated at an initial dose of 0.8 mg/dL, with escalation to 1.0 mg/dL after four doses in the absence of a response. RESULTS Overall, 15 of the 24 patients responded. In the dose-escalation setting, 0.8 mg/dL was the minimal active dose. The total response rate was 62% with doses at or above 0.8 mg/dL and 18% at lower doses. All but one response occurred with 7 or fewer days of therapy, and 9 patients relapsed later. Four additional patients were salvaged following cystoscopy with clot evacuation with or without alum or formalin instillation. In all but 1 patient, bladder spasms developed during treatment with carboprost, but were not sufficiently severe to discontinue therapy. CONCLUSIONS Intravesicular carboprost at 1.0 mg/dL every 6 hours for no more than 7 days should be considered for a randomized study for treatment of refractory hemorrhagic cystitis. Cystoscopic examination and evacuation of clots prior to therapy may be required to achieve the full benefit of this treatment.
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Affiliation(s)
- C Ippoliti
- Department of Hematology, University of Texas M.D. Anderson Cancer Center, Houston
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Marks LB, Carroll PR, Dugan TC, Anscher MS. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int J Radiat Oncol Biol Phys 1995; 31:1257-80. [PMID: 7713787 DOI: 10.1016/0360-3016(94)00431-j] [Citation(s) in RCA: 265] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A comprehensive review of the physiological and clinical response of the urinary bladder, ureter, and urethra to radiation and chemotherapy is presented. The clinical syndromes that follow therapy for cancer of the bladder, prostate, and cervix are reviewed in detail. Methods of assessing, scoring, and managing toxicity are discussed.
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Affiliation(s)
- L B Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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Dewan AK, Mohan GM, Ravi R. Intravesical formalin for hemorrhagic cystitis following irradiation of cancer of the cervix. Int J Gynaecol Obstet 1993; 42:131-5. [PMID: 7901061 DOI: 10.1016/0020-7292(93)90626-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine the effectiveness of intravesical formalin instillation in hemorrhagic cystitis following irradiation of cancer of the cervix. METHOD Records were reviewed for 35 patients with hemorrhagic radiation cystitis who underwent treatment with 1% (n = 22), 2% (n = 10), and 4% formalin (n = 4), using Fair's technique. RESULT Complete response was seen in 31 patients (89%) and partial response in 3 patients (8%) after a single instillation. Minor complications were seen in 19 patients (54%). Major complications occurred in 11 patients (31%), with 5 cases requiring subsequent urinary diversion. One patient died of persistent bleeding and probable formalin toxicity. Hematuria recurred in 7 patients achieving complete response at a mean period of 8 months after treatment. A 1% solution was as effective in controlling hematuria as higher concentrations and was associated with significantly less morbidity. CONCLUSION Intravesical instillation of 1% formalin is an effective treatment for intractable hematuria secondary to radiation cystitis.
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Affiliation(s)
- A K Dewan
- Department of Genitourinary Surgery, Cancer Institute (WIA), Adyar, Madras, India
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Levine LA, Jarrard DF. Treatment of cyclophosphamide-induced hemorrhagic cystitis with intravesical carboprost tromethamine. J Urol 1993; 149:719-23. [PMID: 8455230 DOI: 10.1016/s0022-5347(17)36192-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We review our experience with 18 consecutive patients who received intravesical carboprost tromethamine, an F2-alpha prostaglandin, for severe hemorrhagic cystitis following cyclophosphamide chemotherapy. Of the patients 16 were given cyclophosphamide for conditioning before bone marrow transplantation and 2 received the drug as cytotoxic therapy alone (dose range 3.6 to 15.8 gm.). All patients had severe gross hematuria that was refractory to forced diuresis and to continuous saline bladder irrigation. The intravesical prostaglandin therapy was initiated only after significant transfusion requirements (greater than 1 unit packed red blood cells per day) and/or numerous catheter manipulations for relief of clot retention. Eligible patients underwent complete clot evacuation followed by intravesical instillation of 0.4 to 1.0 mg.% carboprost tromethamine for 2 hours 4 times per day, alternating with continuous saline bladder irrigation for 2 hours. Six patients attempted an alternate protocol of 0.8 to 1.0 mg.% carboprost tromethamine given by continuous saline bladder irrigation. Complete resolution of gross hematuria occurred in 9 patients (50%). Eight patients had a partial response, with decreased transfusion requirements noted. However, complete resolution ultimately required an alternative therapy (for example formalin or urinary diversion). One patient (6%) failed to respond and required formalin therapy on day 4 of carboprost tromethamine therapy. Decreased red blood cell transfusion requirements were noted during and after therapy when compared to pretreatment values. No changes in renal or bladder function were noted during the mean followup of 17 weeks (range 1 to 64 weeks). There were 3 cases of recurrent hematuria. Side effects were limited to bladder spasm in 14 of the 18 patients (78%), with no systemic complications. The results suggest that carboprost tromethamine is a useful bedside therapy for hemorrhagic cystitis due to cyclophosphamide, and treatment appears to have minimal toxicity.
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Affiliation(s)
- L A Levine
- Section of Urology, University of Chicago, Illinois
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Severe hemorrhagic cystitis. Int Urogynecol J 1993. [DOI: 10.1007/bf00376420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Affiliation(s)
- L A Levine
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois 60637
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Abstract
In an extensive search of the literature 235 cases of intractable hemorrhagic cystitis treated with intravesical formalin were identified. Effectiveness of therapy, rate of recurrence of hematuria, morbidity and mortality were analyzed with respect to concentration of formalin and to the etiology of hematuria. Increasing concentrations of formalin slightly improved effectiveness of therapy and reduced the rate of recurrence of hematuria. However, this often resulted in an increase in morbidity. When patients were categorized according to the etiology of intractable hematuria it was noted that lower concentrations of formalin were effective in controlling hematuria caused by either cyclophosphamide cystitis or unresectable carcinoma of the bladder. In contrast, higher formalin concentrations were required to control bleeding due to radiation cystitis.
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Affiliation(s)
- L A Donahue
- Department of Urology, University of Rochester School of Medicine, New York
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Thompson IM, Teague JL, Mueller EJ, Rodriguez FR. Intravesical alum irrigation for intractable bleeding secondary to adenocarcinoma of the prostate. J Urol 1987; 137:525-6. [PMID: 3820393 DOI: 10.1016/s0022-5347(17)44098-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We report on 2 patients in whom intractable hematuria was caused by carcinoma of the prostate. Since the hematuria failed to respond to conservative measures, intravesical 1 per cent alum irrigation was used. Hematuria resolved in both patients and no toxicity was observed. Intravesical alum irrigation should be considered in any patient with significant hematuria secondary to carcinoma of the prostate in whom conservative therapy has failed.
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Kavoussi LR, Gelstein LD, Andriole GL. Encephalopathy and an elevated serum aluminum level in a patient receiving intravesical alum irrigation for severe urinary hemorrhage. J Urol 1986; 136:665-7. [PMID: 3735543 DOI: 10.1016/s0022-5347(17)45009-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Intravesical alum irrigation is reported to be an effective and relatively safe means of controlling severe urinary hemorrhage. We describe a patient who experienced severe encephalopathy, metabolic acidosis and unexplained coagulopathy while receiving continuous intravesical alum irrigation. The serum aluminum level was elevated. The probable role of alum absorption from the bladder as the etiology of the encephalopathy and metabolic abnormalities, as well as the pathophysiology of aluminum metabolism are discussed. Guidelines for the use of intravesical alum irrigation in patients at high risk for the development of these abnormalities are proposed.
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Schellhammer PF, Jordan GH, el-Mahdi AM. Pelvic complications after interstitial and external beam irradiation of urologic and gynecologic malignancy. World J Surg 1986; 10:259-68. [PMID: 3518252 DOI: 10.1007/bf01658142] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Follow-up results of embolization therapy for palliation of incurable bladder carcinoma. World J Urol 1985. [DOI: 10.1007/bf00326723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Goel AK, Rao MS, Bhagwat AG, Vaidyanathan S, Goswami AK, Sen TK. Intravesical irrigation with alum for the control of massive bladder hemorrhage. J Urol 1985; 133:956-7. [PMID: 3999219 DOI: 10.1016/s0022-5347(17)49330-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Continuous vesical irrigation with 1 per cent alum solution was performed without anesthesia in 9 patients in whom massive bladder hemorrhage persisted despite evacuation of clots and normal saline irrigation for at least 24 hours. Hematuria ceased promptly in all patients, although the effect was transient in 3. No side effect was observed. Biopsy of the tumor subsequent to alum irrigation showed no alteration in the histological characteristics. Biopsy of the normal-appearing bladder mucosa also showed no evidence of epithelial damage. Ultrastructure of the tumor in 1 patient in whom transurethral resection was performed 2 weeks after alum irrigation revealed well preserved nuclear chromatin, thus, suggesting that whatever changes occur after alum irrigation are short-lived.
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