Intravesical Instillation Of Formalin Research Articles

Severe pain and hypertension following intravesical instillation of formalin necessitating epidural analgesia

Severe pain and hypertension following intravesical instillation of formalin necessitating epidural analgesia

Improved sacral neuromodulation in the treatment of the hyperactive detrusor: signal modification in an animal model.

To investigate different stimulation signals for the peripheral nerve evaluation test (PNE, carried out before implanting a sacral neuromodulator for functional voiding dysfunction) in an animal model and to determine their efficacy, as up to 80% of patients do not respond to the PNE test. PNE foramen electrodes were placed in the S3 of 12 anaesthetized Göttingen minipigs. First, detrusor instabilities were induced by the intravesical instillation of formalin. A 10-min stimulation phase with both a quasi-trapezoidal (QT) signal and a rectangular signal followed. An interval of 30 min elapsed between the series of stimulations. The attained bladder pressure values were registered on a urodynamic unit and evaluated as contractions and amplitudes per minute. Six minipigs were treated in the same way but were not stimulated and served as a control group. After formalin instillation, the mean (sd) number of involuntary detrusor contractions was 3.5 (0.8)/min and the sum of amplitudes 7.2 (1.1) cmH2O/min. Subsequent NaCl instillation and QT-stimulation reduced the contractions to 0.3 (0.3)/min and the sum of amplitudes to 0.8 (0.4) cmH2O/min. Stimulation with a rectangular signal, as used in the PNE test, followed after an interval of 10 min, giving 1.1 (0.1) contractions/min and a sum of amplitudes of 5.1 (2.4) cmH2O/min. Within the control group there was no significant reduction. These results show that QT-stimulation suppresses uncontrollable detrusor contractions in the minipig more effectively than the conventional rectangular stimulation presently applied in sacral neuromodulation.

Stimulation signal modification in a porcine model for suppression of unstable detrusor contractions

Objectives To investigate, in an experimental study, the efficacy of a different stimulation signal in a porcine model to suppress formalin-induced unstable detrusor contractions. The current mode of stimulation in peripheral nerve evaluation tests and sacral neuromodulation is based on rectangular signal shapes. Published reports, however, have revealed that up to 80% of patients do not respond to peripheral nerve evaluation stimulation. Methods After placement of electrodes at S3 in 12 anesthetized Göttinger minipigs, unstable contractions were induced by intravesical instillation of formalin. Ten-minute stimulation phases with a quasi-trapezoidal signal and a rectangular signal followed. An interval of 30 minutes elapsed between the two series of stimulations. The pressure values were registered on a urodynamic unit and evaluated as contractions and amplitudes per minute. Six minipigs were treated in the same way but were not stimulated and served as the control group. Results After formalin instillation, the average number of involuntary detrusor contractions was 3.5/min (± 0.8) and the sum of amplitudes was 7.2/min (± 1.1). Subsequent NaCl instillation and quasi-trapezoidal stimulation reduced the contractions to 0.3/min (± 0.3) and the sum of amplitudes to 0.8/min (± 0.4). A contraction rate of 1.1/min (± 0.1) and a sum of amplitudes of 5.1/min (± 2.4) were recorded under stimulation with a rectangular signal. In the control group, no significant reduction was recorded. Conclusions The acquired data demonstrate that quasi-trapezoidal stimulation suppresses unstable detrusor contractions in the minipig more effectively than does conventional rectangular stimulation as presently applied in sacral neuromodulation.

NONOPERATIVE MANAGEMENT OF BLADDER PERFORATION WITH SPILLAGE OF FORMALIN AFTER INTRAVESICAL INSTILLATION

The most frequent causes of severe bladder hemorrhage are radiation therapy, unresectable carcinoma of the bladder and cyclophosphamide therapy. Treatments have included vitamin E or estrogen administration, fulguration, urinary diversion, hypogastric artery ligation, 105-aminocaproic acid, hydrostatic pressure balloons, intravesical silver nitrate, aluminum or acetic acid and cystectomy.1 These treatments are often ineffective or associated with major morbidity. Intravesical instillation of formalin was first described by Brown in 1969.2 Since that time, the procedure has been effective in 70% to 100% of the cases, depending on the concentration of formalin used.1 In patients with severe, intractable hematuria formalin instillation is used as a last resort before major surgical intervention or when surgery is not an option. The procedure is generally considered safe and inexpensive but severe complications have been reported. We report a case of bladder perforation with extraperitoneal spillage of formalin after intravesical administration.

Urologic complications of high-dose chemotherapy and bone marrow transplantation

Objective. This study reviews the incidence and management of cyclophosphamide-induced hemorrhagic cystitis in a group of patients who received high-dose chemotherapy and bone marrow transplantation. Methods. The records of 217 consecutive patients undergoing bone marrow transplantation were reviewed. The incidence, degree, and management of hematuria in this group of pancytopenic and immunocompromised patients were recorded. Results. Despite prophylaxis, cystitis developed in 58 of these 217 patients (27%) . In 12 patients (6%) the cystitis was severe. These patients had gross hematuria, clot retention, and drop in hematocrit necessitating blood transfusion. These patients were managed with continuous bladder irrigation, alum irrigation, and when less aggressive approach was unsuccessful, with intravesical formalin instillation. Alum irrigation was used in 5 patients, and was successful in only 1 patient. Six patients required intravesical formalin instillation to control the hematuria. Formalin solution 2–5% was instilled initially. When lower-concentration formalin failed, 5–10% formalin was used progressively. Conclusions. Patients with bone marrow transplantation in whom severe hemorrhagic cystitis develops should be managed aggressively early. Intravesical formalin appears to be the most effective regimen in controlling profuse, persistent hematuria.

Intravesical formalin for hemorrhagic cystitis following irradiation of cancer of the cervix

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.

Intra‐operative pulmonary embolism after intravesical instillation of formalin

Intra-operative pulmonary embolism is a rare and severe complication which is difficult to diagnose. A case is reported in which this condition occurred after intravesical instillation of formalin during radical cystectomy under general anaesthesia. Formalin may be related to formation of intravascular thrombi and result in pulmonary embolism.

Effect of Submucosal Formalin Injection on Bladder Wall in Rats

The effect of intravesical formalin instillation as a therapeutic modality for intractable bladder hemorrhage is well known. And despite clear evidence of therapeutic efficacy of intravesical cytotoxic drugs and/or BCG immunotherapy, there have been substantial recurrences during followup after transurethral resection for superficial bladder tumor. If formalin injected at the bed of superficial bladder tumor is able to coagulate and necrotize the tumor, it will be greatly helpful to the patients With recurrent bladder tumor developed during followup. Since this technique is applicable on outpatient basis, an economical as well as a psychological burden of the patients can be reduced considerably. The purpose of this study is to evaluate the effect of submucosal formalin injection on rat bladder wall, 36 healthy adult male Sprague-Dawley rats (weighing 350gm in average) were divided into 3 groups: In Group I (control group), 0.01ml of normal saline was injected submucosally at the left posterolateral wall of the bladder opened under intraperitoneal Nembutal anesthesia ; In Group II and III, 0.01 ml of 10% and 4% formalin, respectively, were administered at the same site as in the Group I, two rats in each group were sacrificed at day 1, 2, and 3, and week 1, 2 and 4 after injection, respectively. Gross and microscopic examination of the cystectomized specimen were done in each group. In the Group II, bladder stones were formed at week I, and in both the Group I and III, stones were seen at week 2 post injection. There was no significant difference III histologic findings of the bladder between the group II and III. Mucosal ulcer and/or prominent mucosal disruption was observed at 24 hours after injection in both Group II and III. Epithelial regeneration began at day 2, and was marked at day 3, and epithelial lining was almost normalized one week after injection. Subepithelial edema, telangiectasia and inflammatory reaction were prominent at 24 hours post formalin injection. Subepithelial edema persisted in moderate degree for 1 week. Telangiectasia and inflammatory reaction were noted for 4 weeks. Mild degree of these findings also appeared In the control group. Fibroblastic proliferation appeared at day 2 and persisted in moderate degree for 4 weeks. There has been no mortality or bladder perforation. These results suggest that clinical application of this technique is feasible for the selected cases of recurrent, solitary superficial bladder tumor. However, optimal dosage of formalin in relation to the size of the lesion remains to be investigated.

Renal and urinary tract complications following the intravesical instillation of formalin

The case is reported of a 10-yr-old girl who developed intractable hematuria from hemorrhagic cystitis following chemotherapy for a malignant lymphoma. Following the intravesical instillation of formalin, which controlled the hematuria, she developed oliguria attributable to ureteric stenosis and fibrotic contraction of the renal pelves. Bilateral nephrostomies were constructed, but recurrent pyelonephritis and further renal pelvic obstruction developed. A series of renal biopsies and ultimately bilateral nephrectomy revealed severe, chronic interstitial nephritis, massive renal interstitial accumulation of deposits probably containing Tamm-Horsfall protein and, in the left nephrectomy specimen, a florid interstitial chronic granulomatous inflammatory reaction. Although ureterohydronephrosis has been described by others as a complication of the intravesical instillation of formalin, fibrotic contraction of the upper urinary tract and the florid interstitial nephritis with granulomata as described herein have not previously been reported. It is proposed that vesicoureteric reflux of formalin, perhaps accompanied by intrarenal reflux, caused or contributed to these pathological changes.

Intravesical instillation of Formalin for hemorrhagic cystitis secondary to radiation for gynecologic malignancies

Our experience with the use of Formalin instillation in interactable gross hematuria secondary to radiation cystitis in patients with gynecological malignancies is reported. This study indicates coagulative effect of low concentration of Formalin with minimal side effects as a method to control hemorrhage.

Intraperitoneal spillage of formalin after intravesical instillation

Intravesical instillation of formalin appears to be a method of choice in the control of massive hematuria following radiation cystitis. It is generally described as a safe, cheap, effective procedure. We report a case of intraperitoneal spillage of formalin and describe the metabolic and extensive medical problems encountered in the four-week period following the incident before the patient's death.

Ureteral Complications after Intravesical Formalin Instillation

Results of formalin therapy for hemorrhage owing to post-radiation cystitis have been studied with special reference to the frequency and severity of ureteral complications. Gross bleeding stopped in 25 of 27 patients within 48 hours. However, 5 patients became anuric immediately after the instillation and in another 7 patients a transient increase in the serum creatinine level was observed. Urinary diversion was necessary in 11 of the 27 patients. The complication rate in the present study is considerably higher than reported previously. Complications may be explained by vesicoureteral reflux of a too strong formalin-alcohol solution. To avoid future complications we suggest that 1) a high diuresis should be induced peroperatively, 2) a 1 to 2 per cent formalin solution without alcohol should be used and 3) the instillation pressure should not exceed 15cm. water.

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.

Vascular absorption of intravesical formalin in cyclophosphamide induced haemorrhagic cystitis.

Haemorrhagic cystitis was induced in dogs by the administration of cyclophosphamide. The bleeding was stopped by intravesical instillation of Formalin. Vascular absorption of formaldehyde was determined by measurement of serum levels. Progressively increasing amounts in apparent relationship to the concentration of Formalin instilled into the bladder were found in all dogs. Higher serum levels were noted in animals with haemorrhagic cystitis induced by cyclophosphamide than in dogs with normal bladders. This study reinforces our clinical impression that formaldehyde is absorbed continuously through the wall of the urinary bladder in dogs and absorption is related to the concentration gradient. These kinetics should be kept in mind when treating patients with intravescial Formalin in order to prevent the systemic effect of the vascular absorption.

Preventing vesicoureteral reflux during intravesical formalin instillation

A Fogarty embolectomy catheter was used to prevent vesicoureteral reflux during formalin instillation for intractable bladder hemorrhage. The unique use of this catheter is described.

Intravesical instillation of formalin for the management of intractable hematuria.

Intravesical instillation of formalin for the management of intractable hematuria.

Papillary necrosis Result of intravesical instillation of formalin

The management of patients with intractable bleeding from radiation or cyclophosphamide cystitis can create a serious dilemma. However, the use of intravesical formalin shows promise of gaining popularity. A case in which this procedure was used successfully is described. The possible complications of this type of therapy are cited; therefore, it must be approached with caution particularly in respect to dosage.