1608192 © 1990 S. Karger AG, Basel 0302-2838/90/0183-0204S2.75/0
Eur Urol 1990;18:204-206
Intravesical Formalin for the Treatment of Massive Hemorrhagic Cystitis: Retrospective Review of 25 Cases J Vicente, G. Rios, J. Caffaratti Urology Service, Iuna-Fundación Puigvert, Barcelona, Spain
Key Words. Formalin, intravesical ■ Cystitis, hemorrhagic Abstract. Between 1980 and 1988 25 patients with massive bladder hemorrhage were treated with intravesical instillation of 4% formalin in 19 cases and 10% in the remaining 6 cases; the contact time was 15 min in 20 cases. The etiology of the hemorrhage was cyclophosphamide therapy ( 1 case), pelvic radiotherapy ( 15 cases) and infiltrat ing bladder cancer in the remaining 9 cases. In 10 cases, the instillation of formalin was performed in bladders with a prior supravesical diversion. Complications included 1 case of vesicorectal fistula, 1 case of uretero-hydronephrosis and 1 case of vesical extravasation of formalin when a concentration of 10% was used at a volume superior to 50 ml. The only complication seen with 4% formalin was 1 case of upper urinary tract dilatation. Good results were obtained in 88% of cases, who achieved correct hemostasis during a mean of 4 months.
Massive intractable bladder hemorrhage constitutes a life-threatening situation for the patient and makes nec essary the use of urgent measures to control bleeding, although they may be only a palliative or temporary solu tion. The following interventions have obtained poor results: internal iliac artery ligation or embolization [23], cryosurgery [6], hemostatic radiotherapy [31] and in travesical hydrostatic distention [18], Lately other tech niques have been used with success: hyperbaric oxygen [26], Nd: YAG laser photocoagulation [26] and oral ther apy with sodium pentosanpolysulfate [22], Given the clinical seriousness of the situation in a patient in poor general health, it seems logical to choose a topical hemostatic treatment with the intravesical in stillation of a variety of substances: silver nitrate [21], alum [17, 24, 30] and formalin [3, 5, 9, 11, 14-16, 25, 26, 29], The finality of this report is to present our experience with intravesical formalin for the treatment of massive hemorrhagic cystitis.
Materials and Methods During the period of 1980-1988,25 patients who presented with massive hemorrhagic cystitis were treated with intravesical formalin as an urgent hemostatic intervention. We consider that a patient has massive bladder hemorrhage when he/she presents clinical signs of impending hypovolemic shock, an important drop in hematocrit requiring transfusion and maximum intensity hematuria associated frequently with bladder obstruction secondary to clot formation. Twenty-two patients were males and 3 were females; the mean age was 61 years. The etiology of the hemorrhage was radiotherapy in 15 cases, cyclophosphamide treatment in 1 case and infiltrating bladder tumors in the remaining 9 cases. In 3 cases bladder tumors coin cided with pelvic radiotherapy. A pre-instillation cystogram was obtained in all patients (with the contrast instilled under gravity), observing only 1 case of vesi coureteral reflux which required the placement of a Fogarty catheter prior to the instillation of formalin. In 10 of the cases, the patients presented with prior supravesical urinary diversions: 5 ileal conduits, 4 percutaneous nephrostomies and 1 patient with a cutaneous ureterostomy. Therefore approxi mately 40% of formalin instillations were performed in ‘excluded’ bladders (without passage of urine) and the remaining 60% in nor mally functioning bladders. After the placement of a two-way blad der catheter, and with the patient under gneral or intradural anes Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
Introduction
Intravesical Formalin for the Treatment of Massive Hemorrhagic Cystitis
Results Here we evaluate the effectiveness of the hemostatic method used, although a long-term evaluation is difficult as it is dependent upon the evolution of the underlying pathology that caused the hemorrhage. We have obtained good results in 88% of cases (22/25), achieving stable hemostasis during a mean of 4 months (range 1-12 months). Long-term follow-up has demonstrated recurrent hemorrhage in 4 cases (48 months). Nevertheless in another 4 patients the temporary he mostasis obtained, with formalin permitted an optimiza tion of the patients’ general status allowing a salvage cys tectomy to be carried out to permanently control bleed ing (3 ileal conduits and 1 transverse colonic conduit). The evolution of the primary disease caused the death of 11 patients (9 in the first 12 months after treatment).
Discussion Massive intractable hemorrhagic cystitis, in which formalin is indicated for hemostasis is usually secondary to alterations in the bladder wall due to chemical sub stances (cyclophosphamide), ionizing radiation or ad vanced infiltrating bladder tumors [8, 14, 19, 25]. As confirmed experimentally [ 1, 19, 32] and clinically in the human bladder [26], formalin acts locally, causing a precipitation of cellular proteins in the bladder mucosa forming an amorphous protein substance that occludes and fixates the bleeding vessels. In our cases, we have instilled a small amount of for malin, less than 50 ml in 84% of the cases, at low con centrations: 76% of the cases with 4% formalin, and a short period of contact time: 15 min in 80% of cases. After completion of the instillation, the bladder must be washed out using a 10% alcohol solution [3], followed by a continuous bladder irrigation with normal saline [29]. Other authors have used a similar amount of formalin [19]. The concentration of formalin (4%) used in 75% of
our cases is the same as that employed by Chavino et al. [8] and Shah and Albert [26]; in the remaining 25% of the cases, the concentration of formalin was 10% as rec ommended by Barakat et al. [3]. These concentrations, together with a contact time of at least 15 min, are suffi cient to create the amorphous substance which occludes the bleeding vessels and terminates the hemorrhage [32], Although the importance of the length of contact time is under debate, it seems clear that the concentration of formalin is most important in the development of com plications [9]. Godec and Gleich [16], in a review of the literature, found that only 1 of 5 articles described com plications when 4 % formalin was used, compared to 13 of 19 reports that described complications when a con centration of 10% was employed. In a recent review arti cle, Donahue and Franke [10] evaluate the effectiveness of morbidity according to concentration, contact time, etiology of hemorrhage in a total of 235 cases treated with intravesical formalin. At low formalin concentra tions (1-4%), a smaller number of complete responders was obtained although the differences with 10% for malin were not statistically significant. Nevertheless, morbidity and mortality increased when the concentra tion reached 10%. In our experience of a total of 5 com plications, 4 were due to 10% formalin (out of a total of 6 cases) and only 1 complication occurred with 4% for malin (out of 19 cases treated). The complications are difficult to evaluate com pletely given the fact that the instillation is performed in bladders previously altered by surgery of irradiation or affected with end-stage infiltration tumors. We had 1 case of a vesico-rectal fistula in a patient with a sigmoid adenocarcinoma that infiltrated the bladder wall and it was difficult to confirm whether the fistula was produced by the formalin or was secondary to the disease process itself. Nevertheless other authors have described bladder fistulas after the instillation of formalin [12-14], In our experience, the uretero-hydronephrosis wors ened in 2 patients after the instillation and was explained as being secondary to meatal edema [11, 29, 32], If vesi coureteral reflux is present, the involved ureter must be catheterized to avoid injury to the upper urinary tract [20], In our series 40% of the cases corresponded to ‘ex cluded’ bladders where the danger of reflux is negli gible. In cases of low bladder capacity it is necessary to use a small quantity of formalin in order to avoid prevesical extravasation which, if massive enough, may lead to for malin absorption producing toxic [2] or sclerotic [4] Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
thesia, 10% formalin (6 cases) and 4% formalin (19 cases) were instilled intravesically, using a volume greater than 50 ml in 4 cases and less than 50 ml in the remaining 21 (84%). Contact time was 5 min in 5 cases and 15 min in the remaining 20 (80%). Immediately following the instillation, bladder lavage was per formed using 10% alcohol and a continuous bladder irrigation with normal saline was left during 24-48 h.
205
Vicente/Ri os/Caffaratti
206
References 1 Akagi, A.; Otsuka, H.: Nonspecific esterase reaction in hyper plastic urinary bladder epithelium induced by administration of N-butyl-N- (4-hydroxybuty) nitrosamine, freezing and formalin instillation in rats. Br. J. exp. Path. 69: 367-377 (1988). 2 Axelsen, R.A.; Le Ditschke, J.F.; Burke, J.R.: Renal and urinary tract complications following the intravesical instillation of for malin. Pathology 18: 453-458 (1988). 3 Barakat, H.A.; Javadpour, N.; Bush, I.M.: Management of mas sive intractable hematuria. Urology 1: 351-354 (1973). 4 Braam, P.F.; Delaere, K.P.; Debruyne, F.M.: Fatal outcome of intravesical formalin instillation with changes mimicking renal tuberculosis. Urol. int. 41: 451-454 (1986). 5 Brown, R.B.: A method of management of inoperable carcinoma of the bladder. Med. J. Aust. i: 23-24 (1969). 6 Cahan, W.G.; Adam, Y.; Mackenzie, R.A.; Brockumier, A.; Clark, D.G.: Intractable bladder hemorrhage treated by cryosur gery: a preliminary report. J. Urol. 103: 606-611 (1970). 7 Capen, C.; Weigel, S.; Maglina, J.: Masterson, B.: Intraperito neal spillage of formalin after intravesical instillation. Urology 19: 599-601 (1982). 8 Chavino, A.H.; Gill, W.B.; Ruggeiro, K.J.; Wermeulen, C.W.: Experimental cytoxan cystitis and prevention by acetyl cysteine. J. Urol. 134: 598-600(1985). 9 De la Fuente Serrano; Torres, C; Martinez Torres, J.; Nizar Monaffak, L.; Puebla, M.; Navarro, A.; Jimenez, J.; Zuloaga Gomez, A.: Formalizacion vesical. Indicaciones y resultados. Actas Urol. esp. 10: 39-44 (1986). 10 Donahue, L.A.; Frank, I.N.: Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J. Urol. 141: 809-812 (1989). 11 Fair, W.R.: Formalin in the treatment of massive bladder hem orrhage. Techniques, results and complications. Urology 3: 573— 576 (1974). 12 Ferner, B.G.; Reindlee, J.S.H.; Kirk, D.: Paterson, P.J.; Scott, R.: Intravesical formalin in intractable haematuria. J. Urol. 91: 33-35 (1985). 13 Finklestein, L.H.; Arsht, D.: Trenkle, D.: Vesico-ileal fistula: an unusual complication following the use of formalin for control of refractory postirradiation bladder hemorrhage. J. Urol. 117: 168-170 (1977).
14 Firlit, C.F.: Intractable hemorrhagic cystitis secondary to expan sive carcinomatosis: management with formalin solution. J. Urol. 110: 57-58 (1973). 15 Gislason, T.; Noronha, R.: Open instillation of formalin for hemorrhagic cystitis in a child. Urology 18: 496-497 (1981). 16 Godec, C.J.; Gleich, P.: Intractable hematuria and formalin. J. Urol. 130: 688-691 (1983). 17 Goel, A.K.; Rao, M.S.; Bhagwat, A.G.; Vaidyanathan, S.; Gowani, A.K.; Sen, T.K.: Intravesical irrigation with alum for the control of massive bladder hemorrhage. J. Urol. 133: 956-957 (1985). 18 Helmstein, K.: Treatment of bladder carcinoma by hydrostatic pressure technique. Report on 43 cases. Br. J. Urol. 44: 434-450 (1972). 19 Homma, Y.; Oyasu, R.: Transient and persistent hyperplasia in heterotopically transplanted rat urinary bladders induced by for malin and foreign bodies. J. Urol 136: 136-140 (1986). 20 Kalish, M.; Silver, S.J.; Hewing, K.R.: Papillary necrosis: results of intravesical instillation of formalin treatment. Urology 2: 315-317 (1973). 21 Kumar, A.; Wren, E.: Silver nitrate irrigation to control bladder hemorrhage in children receiving cancer therapy. J. Urol. 116: 85-86 (1976). 22 Lowell Parsons, C.: Successful management of radiation cystitis with sodium pentasonpolysulfate. J. Urol. 136: 813-814 (1986). 23 Monneins, F.; Boccon Gibod, L.; Jorest, R.; Merlan, J.J.; Bonnin, P.; Ateg, A.: Le traitement des hématuries graves d’origine vésicale par embolisation sélective des artères de la vessie. Annls Uroi 12: 109-111 (1978). 24 Ostroff, E.; Chenoult, O.: Alum irrigation for the control of mas sive bladder hemorrhage. J. Urol. 128: 929-930 (1982). 25 Ravinovitch, H.H.: Simple innoucuous treatment of massive cyclophosphamide hemorrhagic cystitis. Urology 13: 610-612 (1979). 26 Shah, B.C.; Albert, D.J.: Intravesical instillation of formalin for the management of intractable bladder hematuria. J. Urol. 110: 519-520 (1973). 27 Schoenrock, G.; Cianci, P.: Treatment of radiation cystitis with hyperbaric oxygen. Urology 27: 271-272 (1986). 28 Shanberg, A.M.; Badhassarian, R.; Tanseg, L.A.: Treatment of interstitial cystitis with the Nd-YAG. J. Urol. 134: 885-888 (1985). 29 Spiro, L.H.; Hecht, H.; Horowitz, A.; Orkin, L.: Formalin treat ment for massive bladder hemorrhage complications. Urology 2: 669-671 (1974). 30 Torrecillas, C; Aguilo, F.; Munoz, J.; De La Pena, M.; Serrallach, N.: Irrigación intravesical con solución de aluminio en las hemorragias vesicales incohercibles. Actas Urol. esp. 11: 457460(1987). 31 Vicente Rodriguez, J.; Garat, J.M.; Parea, C.; Vaca, A.; Vail, M.: ‘Hémangiomes vésicaux’. J. Urol. 92: 43-46 (1986). 32 Wittaker, J.; Freed, S.: Effects of formalin on bladder urothelium. J. Urol. 114: 866-870 (1975). J. Vicente, MD Urology Service IUNA-Fundación Puigvert Cartagena 340-350 E-08025 Barcelona (Spain) Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
lesions in upper urinary tract leading to death in some cases [7, 32]. The results were evaluated according to cessation of hemorrhage after the instillation, because the final re sults are conditioned by the evolution of the primary disease. Good results vary between 83.8 and 91.1% [5, 26] according to different authors. We achieved stable hemostasis in 88% of cases for a mean of 4 months. The good results we obtained, together with the low number of complications using a small amount of for malin instilled intravesically at low concentrations (4%) justify the use of this particular substance for the treat ment of massive hemorrhagic unresponsive to conserva tive measures to control bleeding.
Eur Urol 1990;18:204-206
Intravesical Formalin for the Treatment of Massive Hemorrhagic Cystitis: Retrospective Review of 25 Cases J Vicente, G. Rios, J. Caffaratti Urology Service, Iuna-Fundación Puigvert, Barcelona, Spain
Key Words. Formalin, intravesical ■ Cystitis, hemorrhagic Abstract. Between 1980 and 1988 25 patients with massive bladder hemorrhage were treated with intravesical instillation of 4% formalin in 19 cases and 10% in the remaining 6 cases; the contact time was 15 min in 20 cases. The etiology of the hemorrhage was cyclophosphamide therapy ( 1 case), pelvic radiotherapy ( 15 cases) and infiltrat ing bladder cancer in the remaining 9 cases. In 10 cases, the instillation of formalin was performed in bladders with a prior supravesical diversion. Complications included 1 case of vesicorectal fistula, 1 case of uretero-hydronephrosis and 1 case of vesical extravasation of formalin when a concentration of 10% was used at a volume superior to 50 ml. The only complication seen with 4% formalin was 1 case of upper urinary tract dilatation. Good results were obtained in 88% of cases, who achieved correct hemostasis during a mean of 4 months.
Massive intractable bladder hemorrhage constitutes a life-threatening situation for the patient and makes nec essary the use of urgent measures to control bleeding, although they may be only a palliative or temporary solu tion. The following interventions have obtained poor results: internal iliac artery ligation or embolization [23], cryosurgery [6], hemostatic radiotherapy [31] and in travesical hydrostatic distention [18], Lately other tech niques have been used with success: hyperbaric oxygen [26], Nd: YAG laser photocoagulation [26] and oral ther apy with sodium pentosanpolysulfate [22], Given the clinical seriousness of the situation in a patient in poor general health, it seems logical to choose a topical hemostatic treatment with the intravesical in stillation of a variety of substances: silver nitrate [21], alum [17, 24, 30] and formalin [3, 5, 9, 11, 14-16, 25, 26, 29], The finality of this report is to present our experience with intravesical formalin for the treatment of massive hemorrhagic cystitis.
Materials and Methods During the period of 1980-1988,25 patients who presented with massive hemorrhagic cystitis were treated with intravesical formalin as an urgent hemostatic intervention. We consider that a patient has massive bladder hemorrhage when he/she presents clinical signs of impending hypovolemic shock, an important drop in hematocrit requiring transfusion and maximum intensity hematuria associated frequently with bladder obstruction secondary to clot formation. Twenty-two patients were males and 3 were females; the mean age was 61 years. The etiology of the hemorrhage was radiotherapy in 15 cases, cyclophosphamide treatment in 1 case and infiltrating bladder tumors in the remaining 9 cases. In 3 cases bladder tumors coin cided with pelvic radiotherapy. A pre-instillation cystogram was obtained in all patients (with the contrast instilled under gravity), observing only 1 case of vesi coureteral reflux which required the placement of a Fogarty catheter prior to the instillation of formalin. In 10 of the cases, the patients presented with prior supravesical urinary diversions: 5 ileal conduits, 4 percutaneous nephrostomies and 1 patient with a cutaneous ureterostomy. Therefore approxi mately 40% of formalin instillations were performed in ‘excluded’ bladders (without passage of urine) and the remaining 60% in nor mally functioning bladders. After the placement of a two-way blad der catheter, and with the patient under gneral or intradural anes Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
Introduction
Intravesical Formalin for the Treatment of Massive Hemorrhagic Cystitis
Results Here we evaluate the effectiveness of the hemostatic method used, although a long-term evaluation is difficult as it is dependent upon the evolution of the underlying pathology that caused the hemorrhage. We have obtained good results in 88% of cases (22/25), achieving stable hemostasis during a mean of 4 months (range 1-12 months). Long-term follow-up has demonstrated recurrent hemorrhage in 4 cases (48 months). Nevertheless in another 4 patients the temporary he mostasis obtained, with formalin permitted an optimiza tion of the patients’ general status allowing a salvage cys tectomy to be carried out to permanently control bleed ing (3 ileal conduits and 1 transverse colonic conduit). The evolution of the primary disease caused the death of 11 patients (9 in the first 12 months after treatment).
Discussion Massive intractable hemorrhagic cystitis, in which formalin is indicated for hemostasis is usually secondary to alterations in the bladder wall due to chemical sub stances (cyclophosphamide), ionizing radiation or ad vanced infiltrating bladder tumors [8, 14, 19, 25]. As confirmed experimentally [ 1, 19, 32] and clinically in the human bladder [26], formalin acts locally, causing a precipitation of cellular proteins in the bladder mucosa forming an amorphous protein substance that occludes and fixates the bleeding vessels. In our cases, we have instilled a small amount of for malin, less than 50 ml in 84% of the cases, at low con centrations: 76% of the cases with 4% formalin, and a short period of contact time: 15 min in 80% of cases. After completion of the instillation, the bladder must be washed out using a 10% alcohol solution [3], followed by a continuous bladder irrigation with normal saline [29]. Other authors have used a similar amount of formalin [19]. The concentration of formalin (4%) used in 75% of
our cases is the same as that employed by Chavino et al. [8] and Shah and Albert [26]; in the remaining 25% of the cases, the concentration of formalin was 10% as rec ommended by Barakat et al. [3]. These concentrations, together with a contact time of at least 15 min, are suffi cient to create the amorphous substance which occludes the bleeding vessels and terminates the hemorrhage [32], Although the importance of the length of contact time is under debate, it seems clear that the concentration of formalin is most important in the development of com plications [9]. Godec and Gleich [16], in a review of the literature, found that only 1 of 5 articles described com plications when 4 % formalin was used, compared to 13 of 19 reports that described complications when a con centration of 10% was employed. In a recent review arti cle, Donahue and Franke [10] evaluate the effectiveness of morbidity according to concentration, contact time, etiology of hemorrhage in a total of 235 cases treated with intravesical formalin. At low formalin concentra tions (1-4%), a smaller number of complete responders was obtained although the differences with 10% for malin were not statistically significant. Nevertheless, morbidity and mortality increased when the concentra tion reached 10%. In our experience of a total of 5 com plications, 4 were due to 10% formalin (out of a total of 6 cases) and only 1 complication occurred with 4% for malin (out of 19 cases treated). The complications are difficult to evaluate com pletely given the fact that the instillation is performed in bladders previously altered by surgery of irradiation or affected with end-stage infiltration tumors. We had 1 case of a vesico-rectal fistula in a patient with a sigmoid adenocarcinoma that infiltrated the bladder wall and it was difficult to confirm whether the fistula was produced by the formalin or was secondary to the disease process itself. Nevertheless other authors have described bladder fistulas after the instillation of formalin [12-14], In our experience, the uretero-hydronephrosis wors ened in 2 patients after the instillation and was explained as being secondary to meatal edema [11, 29, 32], If vesi coureteral reflux is present, the involved ureter must be catheterized to avoid injury to the upper urinary tract [20], In our series 40% of the cases corresponded to ‘ex cluded’ bladders where the danger of reflux is negli gible. In cases of low bladder capacity it is necessary to use a small quantity of formalin in order to avoid prevesical extravasation which, if massive enough, may lead to for malin absorption producing toxic [2] or sclerotic [4] Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
thesia, 10% formalin (6 cases) and 4% formalin (19 cases) were instilled intravesically, using a volume greater than 50 ml in 4 cases and less than 50 ml in the remaining 21 (84%). Contact time was 5 min in 5 cases and 15 min in the remaining 20 (80%). Immediately following the instillation, bladder lavage was per formed using 10% alcohol and a continuous bladder irrigation with normal saline was left during 24-48 h.
205
Vicente/Ri os/Caffaratti
206
References 1 Akagi, A.; Otsuka, H.: Nonspecific esterase reaction in hyper plastic urinary bladder epithelium induced by administration of N-butyl-N- (4-hydroxybuty) nitrosamine, freezing and formalin instillation in rats. Br. J. exp. Path. 69: 367-377 (1988). 2 Axelsen, R.A.; Le Ditschke, J.F.; Burke, J.R.: Renal and urinary tract complications following the intravesical instillation of for malin. Pathology 18: 453-458 (1988). 3 Barakat, H.A.; Javadpour, N.; Bush, I.M.: Management of mas sive intractable hematuria. Urology 1: 351-354 (1973). 4 Braam, P.F.; Delaere, K.P.; Debruyne, F.M.: Fatal outcome of intravesical formalin instillation with changes mimicking renal tuberculosis. Urol. int. 41: 451-454 (1986). 5 Brown, R.B.: A method of management of inoperable carcinoma of the bladder. Med. J. Aust. i: 23-24 (1969). 6 Cahan, W.G.; Adam, Y.; Mackenzie, R.A.; Brockumier, A.; Clark, D.G.: Intractable bladder hemorrhage treated by cryosur gery: a preliminary report. J. Urol. 103: 606-611 (1970). 7 Capen, C.; Weigel, S.; Maglina, J.: Masterson, B.: Intraperito neal spillage of formalin after intravesical instillation. Urology 19: 599-601 (1982). 8 Chavino, A.H.; Gill, W.B.; Ruggeiro, K.J.; Wermeulen, C.W.: Experimental cytoxan cystitis and prevention by acetyl cysteine. J. Urol. 134: 598-600(1985). 9 De la Fuente Serrano; Torres, C; Martinez Torres, J.; Nizar Monaffak, L.; Puebla, M.; Navarro, A.; Jimenez, J.; Zuloaga Gomez, A.: Formalizacion vesical. Indicaciones y resultados. Actas Urol. esp. 10: 39-44 (1986). 10 Donahue, L.A.; Frank, I.N.: Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J. Urol. 141: 809-812 (1989). 11 Fair, W.R.: Formalin in the treatment of massive bladder hem orrhage. Techniques, results and complications. Urology 3: 573— 576 (1974). 12 Ferner, B.G.; Reindlee, J.S.H.; Kirk, D.: Paterson, P.J.; Scott, R.: Intravesical formalin in intractable haematuria. J. Urol. 91: 33-35 (1985). 13 Finklestein, L.H.; Arsht, D.: Trenkle, D.: Vesico-ileal fistula: an unusual complication following the use of formalin for control of refractory postirradiation bladder hemorrhage. J. Urol. 117: 168-170 (1977).
14 Firlit, C.F.: Intractable hemorrhagic cystitis secondary to expan sive carcinomatosis: management with formalin solution. J. Urol. 110: 57-58 (1973). 15 Gislason, T.; Noronha, R.: Open instillation of formalin for hemorrhagic cystitis in a child. Urology 18: 496-497 (1981). 16 Godec, C.J.; Gleich, P.: Intractable hematuria and formalin. J. Urol. 130: 688-691 (1983). 17 Goel, A.K.; Rao, M.S.; Bhagwat, A.G.; Vaidyanathan, S.; Gowani, A.K.; Sen, T.K.: Intravesical irrigation with alum for the control of massive bladder hemorrhage. J. Urol. 133: 956-957 (1985). 18 Helmstein, K.: Treatment of bladder carcinoma by hydrostatic pressure technique. Report on 43 cases. Br. J. Urol. 44: 434-450 (1972). 19 Homma, Y.; Oyasu, R.: Transient and persistent hyperplasia in heterotopically transplanted rat urinary bladders induced by for malin and foreign bodies. J. Urol 136: 136-140 (1986). 20 Kalish, M.; Silver, S.J.; Hewing, K.R.: Papillary necrosis: results of intravesical instillation of formalin treatment. Urology 2: 315-317 (1973). 21 Kumar, A.; Wren, E.: Silver nitrate irrigation to control bladder hemorrhage in children receiving cancer therapy. J. Urol. 116: 85-86 (1976). 22 Lowell Parsons, C.: Successful management of radiation cystitis with sodium pentasonpolysulfate. J. Urol. 136: 813-814 (1986). 23 Monneins, F.; Boccon Gibod, L.; Jorest, R.; Merlan, J.J.; Bonnin, P.; Ateg, A.: Le traitement des hématuries graves d’origine vésicale par embolisation sélective des artères de la vessie. Annls Uroi 12: 109-111 (1978). 24 Ostroff, E.; Chenoult, O.: Alum irrigation for the control of mas sive bladder hemorrhage. J. Urol. 128: 929-930 (1982). 25 Ravinovitch, H.H.: Simple innoucuous treatment of massive cyclophosphamide hemorrhagic cystitis. Urology 13: 610-612 (1979). 26 Shah, B.C.; Albert, D.J.: Intravesical instillation of formalin for the management of intractable bladder hematuria. J. Urol. 110: 519-520 (1973). 27 Schoenrock, G.; Cianci, P.: Treatment of radiation cystitis with hyperbaric oxygen. Urology 27: 271-272 (1986). 28 Shanberg, A.M.; Badhassarian, R.; Tanseg, L.A.: Treatment of interstitial cystitis with the Nd-YAG. J. Urol. 134: 885-888 (1985). 29 Spiro, L.H.; Hecht, H.; Horowitz, A.; Orkin, L.: Formalin treat ment for massive bladder hemorrhage complications. Urology 2: 669-671 (1974). 30 Torrecillas, C; Aguilo, F.; Munoz, J.; De La Pena, M.; Serrallach, N.: Irrigación intravesical con solución de aluminio en las hemorragias vesicales incohercibles. Actas Urol. esp. 11: 457460(1987). 31 Vicente Rodriguez, J.; Garat, J.M.; Parea, C.; Vaca, A.; Vail, M.: ‘Hémangiomes vésicaux’. J. Urol. 92: 43-46 (1986). 32 Wittaker, J.; Freed, S.: Effects of formalin on bladder urothelium. J. Urol. 114: 866-870 (1975). J. Vicente, MD Urology Service IUNA-Fundación Puigvert Cartagena 340-350 E-08025 Barcelona (Spain) Downloaded by: University of Exeter 144.173.6.94 - 6/8/2020 4:28:43 PM
lesions in upper urinary tract leading to death in some cases [7, 32]. The results were evaluated according to cessation of hemorrhage after the instillation, because the final re sults are conditioned by the evolution of the primary disease. Good results vary between 83.8 and 91.1% [5, 26] according to different authors. We achieved stable hemostasis in 88% of cases for a mean of 4 months. The good results we obtained, together with the low number of complications using a small amount of for malin instilled intravesically at low concentrations (4%) justify the use of this particular substance for the treat ment of massive hemorrhagic unresponsive to conserva tive measures to control bleeding.
