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EDITORIAL COMMENT

The authors are to be commended for this compre- conservative treatment options as initial therapy

hensive evaluation of a cohort of pediatric patientsdemonstrating hemorrhagic cystitis from a largedatabase of patients undergoing chemotherapy.The experience presented corroborates our ownexperience (reference 22 in article) that high gradehemorrhagic cystitis not only is a devastatingcomplication of chemotherapy causing immensepain and physical discomfort to the affected child,but also is a harbinger of disease specific mortality(10 of 15 children with grade IV HC died). Hyper-hydration, mesna coadministration with cyclophos-phamide and continuous bladder irrigation aremainstays of treatment for patients with lowergrades of HC. However, grade IV HC remains anongoing challenge. While the authors rightfully use

for HC, formalin was instilled in 26 patients. Alongitudinal understanding of the sequelae oftoxic formalin instillation in the pediatric popula-tion is unknown, and we would submit that optionssuch as percutaneous nephrostomy placementfor temporary urinary diversion should be consid-ered. This study underlines the need to proceedaggressively in controlling HC and the acute need toprospectively investigate the optimal treatmentfor HC.

Aseem R. ShuklaDivision of Urology

Children’s Hospital of Philadelphia

Philadelphia, Pennsylvania