Intravesical hydrostatic pressure treatment: new method for control of bleeding from the bladder mucosa

Radiation-induced hemorrhagic cystitis

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.

Therapeutic options for intractable hematuria in advanced bladder cancer

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.

Intractable haematuria: long-term results after selective embolization of the internal iliac arteries

OBJECTIVE

To determine the feasibility and efficacy of transarterial embolization (TAE) in haemorrhagic urological emergencies, and to assess the perioperative morbidity, effect of timing of intervention on the requirement for blood transfusion, and the long-term follow-up.

PATIENTS AND METHODS

Between October 1997 and March 2009, 44 patients (30 men and 14 women; mean age 79 years, range 51-95) with intractable haematuria secondary to advanced pelvic tumour arising from or invading the bladder, underwent internal iliac TAE. Twenty-four patients had transitional carcinoma of the urinary bladder, 12 adenocarcinoma of the prostate, five carcinoma of the uterus, one cancer of the vagina, two carcinoma of the rectum, three carcinoma of the kidney, two simultaneous carcinoma of prostate and bladder, one simultaneous carcinoma of prostate and kidney and one had haemorrhagic cystitis after radiotherapy.

RESULTS

TAE of the internal iliac arteries produced initial complete control of bleeding in 36 of the 44 patients (82%). At a mean (range) follow-up of 10.5 (1-97) months TAE there was permanent control of bleeding in 19 (43%) patients. A second TAE session was use in five (11%) patients and it was successful in two of them. There were 24 patients (55%) who required a mean of 4 (1-17) transfusion units before embolization; only 13 (30%) required more blood products after TAE. The mean haematocrit level before and after TAE was 27% and 31% (P < 0001), and the respective haemoglobin level were 8.7 and 10.3 g/dL (P < 0001). During the follow-up there were no major complications related to TAE; minor complications were post-TAE syndrome in 12 (27%) patients, fever (11%), gluteus pain (14%), nausea (2%), and exterior genital oedema (5%). The 6- and 12-month mortality rates were 66% (29 patients) and 18% (eight), respectively.

CONCLUSIONS

TAE should be considered as an alternative less-invasive palliative measure and the treatment of choice in these situations. TAE should always be bilateral, the catheter should advance distally to the origin of the superior gluteal artery and the artery embolized with unresorbable particles. Our study confirms the efficacy and safety of TAE in patients with pelvic malignancy, and indicates that this technique should be considered before surgery. The procedure combines the benefits of a minimally invasive approach in decreasing the cost of surgery and operating time, while maintaining low blood loss and analgesia requirement.

Selective Arterial Embolization of the Vesical Arteries in the Management of Intractable Bladder Hemorrhage

Bleeding from a bladder tumor is a common presentation. Most bleeding can be managed conservatively but on certain occasions bleeding can be severe and hard to control. Sixteen patients who were presented with severe intractable bleeding secondary to bladder tumors and failed conservative management, underwent embolization of branches of the hypogastric arteries to control bleeding. Effective control of bleeding was achieved in 15 patients (94%).

In this review we present our experience in the management of intractable bleeding from bladder tumors by percutanous emobolization in respect of technical success, technique and complications

Massive haemorrhage of inoperable bladder carcinomas: treatment by intravesical formalin solution

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.

Hemorrhagic cystitis in bone marrow transplantation

OBJECTIVES

Patients undergoing bone marrow transplantation are at risk for hemorrhagic cystitis despite appropriate preventive measures. This complication could have an impact on patient survival and other outcome variables.

METHODS

A retrospective study of patients subjected to bone marrow transplantation was conducted to determine risk factors for hemorrhagic cystitis and evaluate the impact of hemorrhagic cystitis on certain outcome variables. Patients who experienced hemorrhagic cystitis received various forms of therapy, at the discretion of the treating physician.

RESULTS

Hemorrhagic cystitis occurred more frequently in younger patients and those undergoing allogeneic transplantation. The occurrence of hemorrhagic cystitis was associated with increased hospital costs, length of hospitalization, and mortality. Gender, race, type of malignancy, other pretransplantation comorbidity, and the occurrence of other peritransplantation complications were not associated with occurrence of hemorrhagic cystitis.

CONCLUSIONS

Hemorrhagic cystitis is a significant complication of bone marrow transplantation, which influences economic and survival outcome. Since the number of bone marrow transplants being performed is increasing, urologists should be prepared to play an active role in treating patients who experience this complication.

Oral conjugated estrogen therapy for treatment of hemorrhagic cystitis

We report 7 cases of severe hemorrhagic cystitis that required repeated transfusions, surgical intervention and oral conjugated estrogens. Of these 7 cases hematuria resolved completely in 5 during estrogen therapy and decreased sufficiently in 1 to preclude further transfusion. We found conjugated estrogens to be an effective, simple, inexpensive, well tolerated and readily available treatment for hemorrhagic cystitis.

Endoscopic neodymium:YAG laser treatment of radiation-induced hemorrhagic cystitis

Hemorrhagic cystitis is a debilitating complication of radiation therapy for pelvic malignancy. Forty-two such patients with intractable hematuria underwent endoscopic Nd:YAG laser coagulation under local anesthesia between January 1990 and July 1992. The laser power was kept at < or = 30 W and the pulse duration < or = 3 s. Control of bleeding was achieved in 39 patients after one sitting and in 2 patients after two sittings of laser treatment. There were no complications of the procedure and recurrence of bleeding was not seen in any of the patients achieving CR at a mean follow-up period of 14 months. With modifications in the safety guidelines, we recommend laser treatment as the initial procedure of choice in patients with hemorrhagic radiation cystitis.

Hemorrhagic cystitis: a review

Acute, fulminant bladder hemorrhage usually is seen at tertiary care centers in which cancer patients are treated with oxazaphosphorine alkylating agents, particularly cyclophosphamide and isophosphamide. These agents also are used to treat benign conditions, such as lupus erythematosis and Wegener's granulomatosis. Radiation effects from treatment of prostatic or cervical carcinoma can appear for the first time as late as 15 to 20 years after initial treatment. Other iatrogenic causes of bleeding include treatment with penicillins and, rarely, danazol. Occasionally, bladder hemorrhage may be the presenting sign of metabolic disease, such as secondary amyloidosis in rheumatic arthritis. Cases of mild to moderate hemorrhagic cystitis arising in the otherwise healthy patients should lead one to pursue the possibility of environmental toxins, accidental poisoning, recreational drug use or viruses. In all cases the diagnosis should be reserved until more common causes of hematuria, such as bacterial or fungal infection, stones, cysts or tumors, have been ruled out. Prevention of chemotherapeutically induced cystitis ideally will follow careful attention to adequate hydration and the prophylactic use of antitoxins, such as mesna. Treatment, as outlined previously, consists of a series of measures beginning with the most conservative. Intervention thereby is tailored to the gravity of the clinical situation.

Reappraisal of hydrostatic pressure treatment for intractable postradiotherapy vesical hemorrhage

Intravesical balloon distention was used in 8 patients to stop intractable hemorrhage after radiotherapy for carcinoma of bladder. We recommend this method of treatment only in patients with no evidence of recurrent or residual invasive tumor in the bladder, where the source of bleeding is from superficial submucosal telangiectatic vessels.

The use of an alum irrigation in the treatment of massive bladder haemorrhage

Severe, massive bladder haemorrhage is a difficult and often frustrating clinical problem. The aetiologies are numerous and include irradiation, malignancy, severe infection and drug-induced changes. Among the numerous modalities of treatment that have been reported formalin, phenol and silver nitrate instillations have often been associated with significant side effects, morbidity and mortality and have had varying degrees of success. During the last two years we have used continuous closed irrigation of a sterile 0.5% alum solution in 16 patients. Alum is an astringent and acts by protein precipitation over the bleeding surface. Because of a low cell permeability its action is limited to the cell surface and interstitial spaces. The permeability of the cell membrane is reduced but remains viable. The preparation and the pharmaceutical aspects of the 0.5% alum irrigation will be discussed. The conclusion is that the technique of managing massive bladder haemorrhage is simple, efficient, nontoxic and less expensive than previously reported therapies. Therefore, irrigation with alum before instituting invasive means to control bleeding is recommended.

Internal iliac artery embolisation for the control of severe bladder and prostate haemorrhage

Embolisation of the internal iliac artery was preformed under local anaesthesia in eight patients with severe bladder haemorrhage and in two with severe bleeding from the prostatic bed after prostatectomy. Good and effective control of the bleeding was achieved in six of the patients with bladder haemorrhage, with a partial response in the other two. Both patients with post-prostatectomy bleeding responded well to embolisation, with prompt cessation of the bleeding. This technique is recommended for the control of severe bleeding from the bladder or prostate in the seriously ill patient.

The Helmstein bladder distension treatment for tumours and severe bleeding

The Helmstein bladder distension treatment was applied to 26 patients, who received a total of 70 treatments (52 for bladder tumour and 18 for severe bleeding; in 7 cases for both tumour and bleeding). In the T2 tumours total necrosis occurred in 27% of the cases, partial necrosis in 50% and no necrosis in 23%. Of the patients with total necrosis 64% had recurrences within 12 months. In the T3-T4 tumours only 33% had a temporary slight reduction of the tumour mass. In patients with severe bleeding from the bladder, haematuria ceased within 1 to 5 days after the treatment in 12 out of 18 cases. Bleeding, however, recurred after an average of 3 months. It is concluded that the treatment is useful in selected cases with multiple tumours of the bladder, and the method is effective in controlling severe bleeding from the bladder.

Encephalopathy and an elevated serum aluminum level in a patient receiving intravesical alum irrigation for severe urinary hemorrhage

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.

Use of alum to control intractable vesical haemorrhage

Eight patients with hitherto uncontrollable vesical bleeding were treated by irrigating the bladder with a 1% solution of alum. The method does not require anaesthesia and bleeding ceased in every case.

Cutaneous ureterostomy as last resort treatment of intractable haemorrhagic cystitis following radiation

Sixteen patients with severe intractable haemorrhagic cystitis following radiotherapy, two of them with bleeding tumours, were treated surgically by cutaneous ureterostomy with or without contralateral nephrectomy. They had undergone various forms of conservative treatment and were treated by surgery only when conservative therapy had failed. In these poor risk patients a cutaneous ureterostomy was employed as a lesser procedure than an ileal loop. Of the 16 who underwent urinary diversion 11 were completely free of haemorrhage and three continued to have slight intermittent haematuria.

Single dose whole pelvis megavoltage irradiation for palliative control of hematuria or ureteral obstruction

Of 7 patients with bladder carcinoma whose medical condition or disease status prevented an operation 5 had intractable vesical hemorrhage and 2 had progressive azotemia caused by ureteral obstruction. These patients were treated with pelvic irradiation of 1,000 rad single doses. Four patients received 3 doses 3 to 4 weeks apart and 1 patient received 2 doses at a 4-week interval. Prompt cessation of bleeding occurred in all patients and renal function improved in the 2 patients with ureteral obstruction.

Topical levarterenol in control of bladder hemorrhage

Topical levarterenol was evaluated for the control of bladder hemorrhage. Its possible toxic effects were investigated in the intact dog bladder, and its use was compared with saline irrigations in experimental massive bladder hemorrhage. Eight mg.% levarterenol was found to be safe and effective in our model.

Prevention of vesicoureteral reflux with Fogarty catheters during formalin therapy

Vesicoureteral reflux during formalin therapy of intractable hemorrhagic cystitis can be prevented with Fogarty catheters inserted cystoscopically into the lower ureters. With this technique formalin instillation and cystography can be done through the cystoscope at the same time. Topical intravesical vasopressin did not, in our experience, lessen the bladder hemorrhage.

Re-evaluation of hydrostatic pressure treatment for malignant bladder lesions

We reviewed 50 cases of bladder cancer treated with the hydrostatic pressure technique. Results were encouraging when 1) single or multiple papillary tumors were not located around the ureteral orifice, with a presumed depth of tumor infiltration within T2, I) there was no history of open operations, 3) there was observed activity of immunological surveillance, for example a positive reaction to a tuberculin test, and 4) management of anesthesia was satisfactory. Hydrostatic pressure therapy is not palliative treatment for far-advanced cases of bladder cancers but should be the first choice for new cases beyond the scope for transurethral operations and when indications in tumor and host condition are satisfied.

An apparatus for Helmstein's hydrostatic pressure treatment

A new method of producing a balloon catheter for distension of the bladder is presented and an appropriate infusion set for the balloon is described. Various advantages and disadvantages have been discussed.

Silver nitrate irrigation to control bladder hemorrhage in children receiving cancer therapy

Silver nitrate irrigations after cystoscopic evacuation of clots stopped intractable hemorrhage from the bladder in 8 of 9 children who had received cyclophosphamide and/or pelvic irradiation for various malignant diseases. This method of management produces fewer adverse side effects yet appears to be as effective as the more drastic measures of control, such as cystectomy or colocystoplasty.

Hydrostatic pressure technique and intravesical instillation of formalin: new methods for the control of severe bleeding from the bladder

Intractable haemorrhages of the bladder in consequence of wide-spread tumours or of haemorrhagic cystitis secondary to radiation therapy involve serious therapeutic problems. Failure of the conventional therapy to bring the haemorrhage under control imposes more active measures so as to avert the danger of exsanguination. The condition of the patients is, however, generally incompatible with major surgery. In this situation the authors resorted to the hydrostatic pressure technique and to intravesical instillations of formalin. Their observations with these procedures are reported.

Hydrostatic pressure treatment for carcinoma of the bladder. A clinical and urodynamic evaluation of the effect on bladder hemorrhage and fibrosis in irradiated patients

Hydrostatic pressure treatment as described by Helmstein was given to 12 patients with hematuria secondary at irradiation for carcinoma of the bladder. The bladder function was evaluated on the basis of urodynamic examinations before and after the treatment. The study includes examination of the effect on the renal function. In 6 patients, hemostasis was obtained for a period averaging 10 months. No serious complications occurred. Following irradiation, the patients showed a characteristic micturition pattern with a small bladder capacity and a marked increase in pressure during the filling phase. The micturition took place partly by use of the abdominal musculature; the detrusor pressure was falling during the whole voiding time. The voiding was almost complete, and the flow values were slightly reduced. The hydrostatic pressure treatment resulted in no demonstrable changes in this micturition pattern. Evaluated from the creatinine clearance, the renal function was unchanged after the treatment, and neither polyuria nor an increased excretion of sodium was demonstrated during the first hours after the treatment. We conclude that before major surgery is decided on, hydrostatic pressure treatment should be given to patients with hemorrhage following irradiation for carcinoma of the bladder. No improvement can be expected in patients where the often pronounced pollakiuria is due to fibrosis of the bladder secondary to irradiation.

Foreign body in lower urinary tract

A forty-four-year-old white man had a stout rubber cable extruding 2 cm. from the external urethral meatus. He had introduced an 82-cm. rubber cable via his urethra into his bladder to assist in clearing dysuria and hematuria. Suprapublic removal of the rubber cable was accomplished, and his postoperative course was benign.