What is the best course of treatment for a patient with metastatic bladder cancer presenting with gross hematuria?

Management of Gross Hematuria in Metastatic Bladder Cancer

For a patient with metastatic bladder cancer presenting with 500 cc gross hematuria, immediate management should focus on hemodynamic stabilization, bladder irrigation with continuous saline through a three-way catheter, and consideration of palliative transurethral resection of bladder tumor (TURBT) as first-line intervention, followed by palliative radiotherapy or arterial embolization if bleeding persists. 1, 2

Immediate Stabilization and Assessment

• Establish large-bore intravenous access and initiate fluid resuscitation while obtaining complete blood count, coagulation studies, and type and crossmatch for potential transfusion 2, 3
• Insert a large-bore three-way Foley catheter (22-24 Fr) and initiate continuous bladder irrigation with normal saline to prevent clot formation and maintain catheter patency 2, 3
• Assess hemodynamic status and transfuse packed red blood cells as needed to maintain hemoglobin >7-8 g/dL in stable patients or higher thresholds if symptomatic 2
• Continue anticoagulation or antiplatelet therapy if present, as the underlying malignancy requires evaluation regardless of medication use 1

Stepwise Treatment Algorithm

First-Line: Palliative TURBT

• Perform palliative transurethral resection to debulk bleeding tumor tissue and achieve hemostasis 1
• This provides immediate mechanical control of bleeding and is the preferred initial intervention when feasible 2, 3
• The goal is hemostasis and symptom relief, not complete tumor resection, given the metastatic context 1

Second-Line: Palliative Radiotherapy

• If TURBT fails or is not feasible, initiate palliative external beam radiotherapy (typically 20-30 Gy in 5-10 fractions) 1, 2
• Radiotherapy achieves hemostasis in 60-80% of cases within 2-4 weeks 2, 3
• This is particularly effective for locally advanced disease causing bleeding 1, 2

Third-Line: Intravesical Therapies

If bleeding persists after TURBT and radiotherapy:

• Intravesical alum irrigation (1% aluminum ammonium sulfate or aluminum potassium sulfate) via continuous bladder irrigation for 24-72 hours is the preferred intravesical option due to favorable safety profile 2, 3
• Intravesical formalin (1-10% solution) can be considered but carries significant risk of bladder fibrosis, vesicoureteral reflux, and potential renal failure; should be reserved for refractory cases only 2, 3
• Formalin requires general or spinal anesthesia and cystoscopy to ensure no vesicoureteral reflux before instillation 2

Fourth-Line: Interventional Radiology

• Superselective arterial embolization of the internal iliac or vesical arteries is highly effective (80-90% success rate) for refractory bleeding 4, 3
• This minimally invasive approach targets bilateral superior and inferior vesical arteries 4
• Complications include bladder necrosis, buttock claudication, and sexual dysfunction, but these are relatively uncommon 4, 3

Fifth-Line: Systemic Hemostatic Agents

• Oral epsilon-aminocaproic acid (5 g loading dose, then 1-1.25 g/hour or 4 g every 4 hours) inhibits fibrinolysis and may reduce bleeding 2, 3
• Risk of thrombosis limits use, particularly in patients with metastatic cancer who are already hypercoagulable 3

Last Resort: Urinary Diversion

• Palliative cystectomy with urinary diversion should be considered only when all other measures fail and the patient has reasonable performance status and life expectancy 1, 2
• This carries significant morbidity in the metastatic setting but provides definitive control 2, 3

Concurrent Systemic Management

• Initiate or continue systemic chemotherapy for metastatic disease if performance status allows, as tumor response may reduce bleeding 1
• For cisplatin-eligible patients, gemcitabine/cisplatin is the preferred first-line regimen 1
• For cisplatin-ineligible patients, carboplatin-based regimens or checkpoint inhibitors may be considered 1

Critical Pitfalls to Avoid

• Do not delay intervention waiting for spontaneous resolution; gross hematuria in metastatic bladder cancer rarely resolves without treatment 1, 2
• Do not use intravesical formalin as first-line therapy due to severe potential complications including bladder contracture and renal failure 2, 3
• Do not perform cystoscopy or TURBT in unstable patients; stabilize hemodynamics first with irrigation and transfusion 2
• Do not assume bleeding will stop with systemic chemotherapy alone; local control measures are typically required 2, 3

Prognosis and Goals of Care Discussion

• The critical concern for metastatic bladder cancer is prolonging quantity and maintaining quality of life, not cure 1
• Median survival with metastatic disease is 12-15 months even with optimal systemic therapy 1
• Early palliative care consultation should be integrated to address goals of care, particularly if multiple interventions are required 1