徐偉巽^1,2、周永強^1,2,3、陳建志^1,2,3、邱文祥^1,2,3

¹馬偕紀念醫院泌尿科、²馬偕醫學院、³馬偕醫護管理專科學校

Wei-Hsun Hsu^1,2 , Yung-Chiong Chow^1,2,3 , Marcelo Chen^1,2,3 , Allen W. Chiu^1,2,3

¹Department of Urology, Mackay Memorial Hospital, Taipei, Taiwan;

²Mackay Medical College, Taipei, Taiwan;

³Mackay junior College of Medicine, Nursing, and Management, Taipei, Taiwan

 

Intractable bladder hemorrhage is a common clinical problem. For patients with persistent gross hematuria after conservative treatment or cystoscopy with evacuation of blood clot, various agents were investigated. Epinephrine, a potent alpha- and beta-adrenergic receptor agonist, is usually clinically used as a blood vessel constrictor and hemostatic agent. We investigated the safety and efficacy of intravesical epinephrine instillation for patient with intractable bladder hemorrhage.

Following Institutional Review Board approval, we identified 22 patients treated with intravesical instillation of epinephrine at Mackay Memorial Hospital since 2008 to 2011. All patients had failed previous bladder irrigation with normal saline or blood clot evacuation with cystoscopy. We used diluted 0.1-fold epinephrine (Adrenaline 1mg/1mL amp) solution (50 mg epinephrine plus 450 c.c. normal saline) cystoscopic intravesical retention. We retained 150 c.c. 0.1-fold diluted epinephrine for three minutes each time and drain out after that. The procedure was repeated three times. During operation, the vital signs of the patients were monitored by anesthesiologists. After operation, we used continuous bladder irrigation with 0.01-fold diluted epinephrine solution and tapered the concentration gradually according to the performance of hematuria. Successful management was defined as hematuria resolution after epinephrine instillation without use of additional invasive treatment within one month.

Median patient age was 57 years (IQR 46.3, 73). Radiation gynecologic cancer was the most common etiology (n=8, 36.4%). The average length of hospitalization was 15.5 days (IQR 2.3, 13.3) and average follow-up duration was 35.3 months (IQR 2, 55). In total, 20 (90.9%) patients required no addition therapy after intravesical epinephrine instillation within one month. The other two (9.1%) patients required additional therapy. One received therapeutic embolization 10 days after epinephrine instillation and the other underwent evacuation of clot and fulguration with cystoscopy twice for bleeding control. The median recurrence time was 3.4 months (IQR 1, 5) in 21.7% patients. None had adverse effect including tachycardia, dyspnea, headache during or after intravesical epinephrine instillation and no clinical evidence of significant systemic absorption was found.

In our study, intravesical epinephrine instillation is a safe and well-tolerated alternative treatment for intractable bladder hemorrhage in 90.9% of patients.