Intravesical Agents in the Treatment of Bladder Clots in Children

Abstract

Bladder blood clots represent an infrequent urinary condition in children. They usually result from hematuria with many underlying causes, such as urinary tract infections and urethral/bladder traumas. Treatment options for clot removal include trans-urethral or suprapubic bladder irrigation and, if unsuccessful, endoscopic management under general anesthesia with a resectoscope. In younger male children, however, the repeated passage of a trans-urethral resectoscope may be challenging and traumatic, due to the small lumen diameter. Eventually, an open surgical approach can be required in many patients. Few anecdotal non-surgical approaches have been proposed for the management of bladder blood clots in children. This review aims to summarize the conservative techniques described in the literature with the instillation of intravesical agents, analyzing the different strategies and their advantages.

Urethral Sheath to Evacuate Blood Clots through Mitrofanoff Appendicovesicostomy

“…Lastly, Olarte et al managed a critical neonate in ECMO support with alteplase to dissolve a big clot [12]. Similar approaches with different agents, such as chymotrypsin plus sodium bicarbonate and hydrogen peroxide, have been described in adults and lack data in pediatric patients [7]. In the presented case, intravesical agents instillation was not taken into account as the patient had an ileocystoplasty.…”

“…The bladder clots management usually consists of drainage with large-bore catheters and manual irrigation [7,9]. In case of failure, surgical approaches, intravesical agent instillation and endoscopic procedures have been described for bladder clot evacuation, and the preferrable choice depends on the characteristics of the patient, the surgeon's expertise and the hospital equipment availability.…”

“…Intravesical agents are a group of substances that, after a trans-catheter bladder instillation, reduce the consistence or disintegrate the blood clots due to their enzymatic or chemical activity [7]. The first attempt in 1993, described by LaFave and Decter, involved a successful clot dissolution after intravesical urokinase in two boys [10].…”

“…Once abdominal ultrasonography (US) has confirmed the diagnosis, manual bladder irrigation with large-bore catheters constitutes a feasible and suggested strategy to progressively clear the urine and allow the aspiration of clots. Computed tomography (CT) should precede any invasive maneuver in a trauma setting to avoid the risk of further damages on an injured lower urinary tract [7]. In neobladders, the symptomatology is usually more nuanced, consisting of abdominal pain or tension and dysuria or difficulties in catheter drainage.…”

“…The percutaneous approach and open cystotomy are also the eligible strategies in case of non-catheterizable urethra (surgical closure of bladder neck, severe urethral stricture and neobladder), but they are still invasive-even if minimally-approaches; therefore, they require the operatory room availability and the anesthesiologic support [7].…”