title: Intravesical silver nitrate for refractory hemorrhagic cystitis.
abstract: OBJECTIVE
  Hemorrhagic cystitis is a challenging clinical entity with limited evidence available to guide treatment. The use of intravesical silver nitrate has been reported, though supporting literature is sparse. Here, we sought to assess outcomes of patients treated with intravesical silver nitrate for refractory hemorrhagic cystitis.
  
  
  METHODS
  We identified nine patients with refractory hemorrhagic cystitis treated at our institution with intravesical silver nitrate between 2000-2015. All patients had failed previous continuous bladder irrigation with normal saline and clot evacuation. Treatment success was defined as requiring no additional therapy beyond normal saline irrigation after silver nitrate instillation prior to hospital discharge.
  
  
  RESULTS
  Median patient age was 80 years (IQR 73, 82). Radiation was the most common etiology for hemorrhagic cystitis 89% (8/9). Two patients underwent high dose (0.1%-0.4%) silver nitrate under anesthesia, while the remaining seven were treated with doses from 0.01% to 0.1% via continuous bladder irrigation for a median of 3 days (range 2-4). All nine patients (100%) had persistent hematuria despite intravesical silver nitrate therapy, requiring additional interventions and red blood cell transfusion during the hospitalization. There were no identified complications related to intravesical silver nitrate instillation.
  
  
  CONCLUSIONS
  Although well tolerated, we found that intravesical silver nitrate was ineffective for bleeding control, suggesting a limited role for this agent in the management of patients with hemorrhagic cystitis.
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Montgomery
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Ziegelmann
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Joyce
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Linder
keywords: Bladder; hematuria; hemorrhagic cystitis; intravesical; silver nitrate