General Approach to Treatment

The treatment of hemorrhagic cystitis first involves discontinuation of the offending agent. Agents such as anticoagulants and inhibitors of platelet function should also be discontinued. IV fluids should be aggressively administered to irrigate the bladder. Blood and platelet transfusions may be necessary to maintain normal hematologic values. Pain should be managed with opioid analgesics. Local intravesicular therapies may be necessary if hematuria does not resolve (Fig. 99-3).

Nonpharmacologic Therapy

A large-diameter, multihole urethral catheter should be inserted to facilitate saline lavage and evacuation of blood clots. Surgical removal of blood clots under anesthesia may be required if saline lavage is ineffective. Active bleeding from isolated areas may be cauterized with an electrode or laser. In severe cases that are unresponsive to local or systemic pharmacologic intervention, urinary diversion with percutaneous nephrostomy or surgical removal of the bladder may be required.

Table 99-12 ASCO Guidelines for the Use of Mesna With Ifosfamide and High-Dose Cyclophosphamide

Chemothe

Schedule

Dosing Schedule for Menu

Comment*

High-dose Itoilamide

GlCfllCr (hjn ij/m /day

Standard dose eye lophospfiamide Hiqli-tViW cytlophOiphsnnKle Lbiirw rnnf transptanl '.■

Oiih lOWbol kjidi üjiiyttoíí c< ¡rsJjínkíegi/wi ÍOUIV lí mlnnies before "Wfc po 2 inri t Italic dilct iliiM of ilotifdmldc

Bolus. oí lolaldjilydoaoof ifosfamkio given W in ¡nf (einf nn i i mamKj t>eí<>e ¿no J ¿no e frjuii. aim m.ki of ikfif.sniKlr

IrifuyofK W96 eitofjIJjily ítOW íH JwfjiirtiíJíí ■givtn ?OW IVmlnum before and Oírtt by continuous infusion dmiog jpd fai 12-24Jioursarrci (.-ndof fcMdi

Lack of evidence far dosing tawever higher doses 1ut fcmgtT durillwi recommended b*scd on kHV^f'i I LIII1-lin iif IfosfMnidf likjh Uw of mesna is not routinely necessary Bolus- JCrtt erf C ytk>gyv>4CilwnkJe CfcWi? P/M

horns G, i b, and 9 ailer cyckjpfrospfriamide Infuyon 100% OI ¿ydüptyBjjhürnide düíí giw.fi Dytoniliniíous infusion imnii 24 hoois aitei cyclophosphamide

AujiUtiie in 400-iflg (jbioit

Peik uiiii.ify (hlot concentrations «lili oral rrKiiH is ut 3 S>ouit II fntlKrll rtjmlfi nilhin 2 htXlfiOf adminWijtioíi, nppeji fío*? ofíllyof W

FYnk urinary thiol oonctnLiatlons with IV

frtfjft) Ijjf 1 hour Compatible wiih tftftfamide iind i^tlüptraifihjmidíj ly V-ille jdmlnbualion Oi v/w^ilrnixixr in rlH' mine 15*1

ASdjÜ. American Society of Liintjl Uncofogy. Ficm 1W. .Ifi.

Pharmacologic Therapy

A number of local or systemic agents are utilized in the treatment of hemorrhagic cystitis.45 Local (direct instillation into the bladder), one-time administration of hemostatic agents such as alum, prostaglandins, silver nitrate, and formalin may be used; however general anesthesia is required, especially with formalin due to pain. Systemic agents including estrogens, vasopressin, and aminocaproic acid may be used in patients who are refractory to local therapy, although they introduce the risk of systemic side effects. These agents should be continued until bleeding stops.

Refractoriness Ooioid Analgesia
FIGURE 99-2. Examples of mesna administration with ifosfamide.
Hemorrhagic Cystitis
FIGURE 99-3. Treatment of hemorrhagic cystitis. (From Ref. 27.)

Antispasmodic agents such as oxybutynin 5 mg by mouth 2 to 3 times daily may be used for bladder spasms. In patients with refractory pain, opioid analgesics should be titrated to adequate pain control.

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