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.