Vesical instillations of hyaluronic acid to reduce the acute vesical toxicity caused by high-dose brachytherapy do not affect the survival: a five-year follow-up study

Hyaluronic acid to manage radiotoxicities in gynecological cancer patients: a scoping review

PURPOSE

This study aimed to map the use of hyaluronic acid (HA) in preventing and controlling radiotoxicity in women with gynecological cancer undergoing radiotherapy.

METHODS

We conducted a scoping review of eight electronic databases: CINAHL, Cochrane CENTRAL, LILACS, PubMed, Scopus, Embase, LIVIVO, and the Web of Science Core Collection. In addition, a grey literature search was performed using Google Scholar and ProQuest Dissertations & Theses Global. A manual search was also identified additional references. The search was conducted on May 18, 2023. We included primary studies, reviews, and guidelines that discussed the use of HA to prevent and manage the toxicities resulting from gynecological radiotherapy.

RESULTS

Eighteen studies were included in this scoping review, published between 2009 and 2022. There was heterogeneity in the use of HA, particularly in the method of application (moisturizing gel, vaginal ovules, spacer gel, and bladder instillations). Furthermore, the radiotoxicities varied among studies, encompassing, among others, vaginal atrophy, dryness, dyspareunia, telangiectasis, adhesions, vaginal stenosis, bleeding, hematuria, and bladder issues. Most studies addressed the potential benefits of HA in managing the signs and symptoms resulting from radiotherapy.

CONCLUSION

HA has been utilized in clinical practice, in various formulations, for managing signs and symptoms in patients with gynecological cancer undergoing radiotherapy. However, further studies are necessary to thoroughly investigate the most effective method of HA application and its effectiveness in managing radiotoxicity.

Advances in the management of radiation-induced cystitis in patients with pelvic malignancies

OBJECTIVE

Radiotherapy plays a vital role as a treatment for malignant pelvic tumors, in which the bladder represents a significant organ at risk involved during tumor radiotherapy. Exposing the bladder wall to high doses of ionizing radiation is unavoidable and will lead to radiation cystitis (RC) because of its central position in the pelvic cavity. Radiation cystitis will result in several complications (e.g. frequent micturition, urgent urination, and nocturia) that can significantly reduce the patient's quality of life and in very severe cases become life-threatening.

METHODS

Existing studies on the pathophysiology, prevention, and management of radiation-induced cystitis from January 1990 to December 2021 were reviewed. PubMed was used as the main search engine. Besides the reviewed studies, citations to those studies were also included.

RESULTS AND DISCUSSIONS

In this review, the symptoms of radiation cystitis and the mainstream grading scales employed in clinical situations are presented. Next, preclinical and clinical research on preventing and treating radiation cystitis are summarized, and an overview of currently available prevention and treatment strategies as guidelines for clinicians is provided. Treatment options involve symptomatic treatment, vascular interventional therapy, surgery, hyperbaric oxygen therapy (HBOT), bladder irrigation, and electrocoagulation. Prevention includes filling up the bladder to remove it from the radiation field and delivering radiation based on helical tomotherapy and CT-guided 3D intracavitary brachytherapy techniques.

Radiation Proctitis: The Potential Role of Hyaluronic Acid in the Prevention and Restoration of Any Damage to the Rectal Mucosa among Prostate Cancer Patients Submitted to Curative External Beam Radiotherapy

Aim: To evaluate if hyaluronic acid reduces proctitis episodes with respect to corticosteroids in prostate cancer patients submitted to radical or adjuvant radiotherapy. Methods: A consecutive series of eligible patients received hyaluronic acid enemas as supportive care (experimental group, from January 2013 to June 2015). A historical group (control group), treated from October 2011 to December 2012, received beclomethasone dipropionate suppositories. We registered each patient’s data regarding acute and chronic proctitis. All patients were treated with static-intensity-modulated radiotherapy coupled to a daily set-up verification with orthogonal anterior–posterior/lateral X-ray pairs. Results: A total of 269 patients, 175 in the experimental group and 94 in the control group, was evaluated; 2 Gy/day (up to a total median dose of 80 Gy) and 2.7 Gy/day (up to a total median dose of 67.5 Gy) fractionation schemes were used for 216 and 53 patients, respectively. All patients had a good tolerance to radiotherapy, reporting no G3 or greater proctitis. No significant difference was reported concerning the total rate of proctitis between the two groups but only with respect to its grade: a higher G2 rate within the control group. There was no correlation between daily dose fractionation and toxicity grade. Conclusions: Hyaluronic acid enemas might be effective in reducing the severity of radiation proctitis.

Intravesical Glycosaminoglycans Experience for Chronic Lower Urinary Tract Pathology Treatment

Objective Intravesical glycosaminoglycans (GAG) treatment is one of the therapeutic options for chronic bladder pathologies and is approved for Bladder Pain Syndrome (BPS), radiation cystitis, and recurrent urinary tract infections (UTIs). The purpose of this study is to describe the demographic characteristics of patients with such pathologies in our population and to evaluate treatment response.

Methods It is a retrospective study of patients with the aforementioned pathologies, who received treatment with GAG. Demographic characteristics and subjective improvement with treatment were evaluated. A bivariate analysis was performed to study possible improvement predictors.

Results 53 patients were evaluated. Of them, 33 (62.3%) with BPS, 12 (22.6%) with recurrent UTIs, and 8 (15.1%) with radiation cystitis. The dose range received was between 4 - 20 instillations, with a median of 6 doses. 67.9% of patients showed improvement of symptoms with treatment, this percentage being even higher for the group of patients with recurrent UTIs (91%). No treatment response predictors were found.

Conclusions Intravesical GAG treatment is a therapeutic alternative for patients with chronic bladder pathologies, with satisfactory results in the medium term. Prospective studies are needed to support the findings of this study.

Subcutaneous Injection of Hyaluronic Acid to Decrease Acute Skin Toxicity After Adjuvant Interstitial Brachytherapy in Parotid Gland Cancer Patients: A Nonrandomized Controlled Trial

PURPOSE

The aim was to evaluate the safety and efficacy of subcutaneous injection of hyaluronic acid in decreasing acute skin toxicity after adjuvant interstitial brachytherapy in parotid gland cancer patients.

MATERIALS AND METHODS

Patients with histologically proven parotid gland cancer who would be treated with adjuvant interstitial brachytherapy were included in this nonrandomized controlled trial. Participants were nonrandomly divided into the experimental group and control group. Participants in the experimental group received an injection of hyaluronic acid subcutaneously immediately after interstitial brachytherapy during the operation. Acute toxicity was evaluated in the first 2 months.

RESULTS

Thirty consecutive participants were included from April to September 2018. Twenty participants were in the experimental group, and 10 were in the control group. The median volume of hyaluronic acid was 8 mL (range, 4 to 11 mL). In total, the incidence of acute skin toxicity was 40% (8 of 20 patients) and 100% (10 of 10 patients) in the experimental group and control group, respectively. The difference in the dose delivered to 90% of the target volume of the affected skin was significant between the pre-plan (mean, 36.93 Gy) and the actuarial quality verification (mean, 27.70 Gy) in the experimental group (P = .004). The difference in scoring of acute skin toxicity was significant between the experimental and control groups (P = .001). No clear correlation was found between the dose delivered to 90% of the target volume of the affected skin and the scoring of acute skin toxicity (P = .266).

CONCLUSIONS

Subcutaneous injection of hyaluronic acid was safe and efficient in decreasing acute skin toxicity after adjuvant interstitial brachytherapy in parotid gland cancer patients according to the preliminary results.

[Medical prevention and treatment of radiation-induced urological and nephrological complications]

Abdominal and pelvic irradiations play a major place in the management of patients with cancer and present a risk of acute and late side effects. Radiation-induced lesions can affect kidney or urological structures. These side effects can have an impact in the quality of life of patients. The aim of this article is to describe the physiopathology, the symptomatology, and the principles of management of radiation-induced nephropathy, uretheritis, cystitis, and urethritis.

Guidelines for the diagnosis, prevention and management of chemical- and radiation-induced cystitis

Objective

Haemorrhagic cystitis (HC) is a relatively common complication of chemotherapy and radiotherapy to the pelvic area, but can be a challenging condition to treat, particularly since there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.

Materials and methods

A comprehensive literature search was undertaken to evaluate the evidence for the diagnosis, prevention and management of cancer treatment-induced HC.

Results

Recommendations and a proposed management algorithm for the diagnosis, prevention and treatment of HC, as well as the management of intractable haematuria, have been developed based on the expert opinion of the multidisciplinary consensus panel following a comprehensive review of the available clinical data.

Conclusion

These guidelines are relevant and applicable to current clinical practice and will help clinicians optimally define and manage this potentially serious condition.

Bladder Instillation Therapy With Hyaluronic Acid and Chondroitin Sulfate Improves Symptoms of Postradiation Cystitis: Prospective Pilot Study

BACKGROUND

After radiotherapy (RT) for prostate cancer (PCa), several patients reported lower urinary tract symptoms (LUTS) due to damage and discontinuation of the glycosaminoglycan layer of the bladder. Instillation of hyaluronic acid and chondroitin sulfate (HA-CS) represents replenishment therapy of the glycosaminoglycan layer. The aim of the study is to evaluate the efficacy and safety of HA-CS in men with symptomatic cystitis after RT for PCa.

MATERIALS AND METHODS

Eighty consecutive men were treated with RT for PCa; 30 of these (37.5%) reported clinically relevant LUTS and associated bother as measured by the Interstitial Cystitis Symptom Index and Problem Index (ICSI/ICPI) Questionnaire 3 months after RT. Symptomatic patients received instillation therapy with HA-CS weekly for the first month and then at weeks 6, 8, and 12. All patients completed the ICSI/ICPI questionnaire before and after RT and at the end of HA-CS treatment.

RESULTS

HA-CS significantly reduced postradiation LUTS (P < .001) and bother (P = .006). Age, Gleason score, and radiation dose were the main determinants of worsening of LUTS after radiation (ICSI score baseline vs. postradiation: P = .047, .043, and .023). In multivariate analysis, only age influenced LUTS worsening after RT (P = .01). Age, radiation dose, and radiation toxicity were related to recovery of LUTS (ICSI score postradiation vs. post-HA-CS P = .041, P = .050, and P = .046). In multivariate analysis, no factor was statistically significant.

CONCLUSIONS

A remarkable worsening of symptoms and bother was observed after RT. HA-CS instillation is a safe treatment and resulted in an improvement of LUTS irrespective of age and clinical features, with full recovery of urinary bother.

Intravesical Therapies for Radiation Cystitis

Objective

The purpose of this study was to summarize developments during the last decade in intravesical treatments for radiation cystitis. Radiation used to treat pelvic malignancies inadvertently damages the urinary bladder leading to acute as well as chronic symptoms. Late sequelae may take years to develop and include storage symptoms and hematuria, which may be life-threatening in severe cases. Conservative measures, surgical interventions, and systematically or intravesically administered agents represent treatment choices.

Methods

MEDLINE and PubMed were searched to retrieve clinical data on the subject, published in peer-reviewed journals from 2002 onwards.

Results

Historically referenced intravesical treatments such as aluminium salts and formalin, were not investigated in recent studies. The replenishment of the glycosaminoglycan layer of the bladder mucosa shows promise in reducing acute symptoms and possibly long-term bladder damage, but needs further investigation. Botulinum toxin also represents a new alternative treatment for radiation cystitis but its mechanism of action and efficacy should be evaluated in future trials.

Conclusion

There is a paucity of data in recent literature regarding the management of radiation cystitis, at least by means of intravesical agents. The replenishment of the glycosaminoglycan layer of the bladder mucosa and the administration of botulinum toxin show promise, but need further investigation.

The use of intravesical hyaluronic acid for recurrent urinary tract infections in children: a case-series study

BACKGROUND

This is the first study performed to evaluate the effects of intravesical hyaluronic acid (IHA) instillation on diminishing the frequency of recurrent urinary tract infections (UTIs) in children.

METHODS

Fifteen children (10 girls, 5 boys) with recurrent UTIs were divided into two groups as either complicated (group 1) (with accompanying disorders including vesicoureteral reflux or neurogenic bladder) or uncomplicated patients (group 2). After administration of weekly four sessions of IHA therapy the patients were followed-up monthly for 2 years and classified as responsive (complete/partial) or unresponsive to treatment.

RESULTS

53.3% of the patients with recurrent UTIs were complicated. In group 1 (n = 8), complete and partial response rates were 62.5% (n = 5) and 25% (n = 2), respectively. There was no response in 12.5% (n = 1) of the cases in group 1. In group 2 (n = 7), complete and partial response rates were 71.4% (n = 5) and 14.3% (n = 1), respectively. In this group, 14.3% (n = 1) of the patients were found to be unresponsive to IHA treatment. No side effects were observed in any of the patients.

CONCLUSIONS

IHA administration is considered as an effective treatment modality which significantly reduces the prevalence of or even provides complete recovery from recurrent UTIs in childhood. Therefore, it is believed that this approach can be used as a promising alternative to widespread use of antibiotics in this patient group.

Efficacy and safety of pirarubicin combined with hyaluronic acid for non-muscle invasive bladder cancer after transurethral resection: a prospective, randomized study

OBJECTIVE

To verify the efficacy and safety of intravesical instillation of pirarubicin combined with hyaluronic acid after TURBT in non-muscle invasive bladder cancer patients.

METHODS

We conducted a prospective study recruiting 127 eligible patients from 2008 to 2010. Patients were randomly assigned to Group A (pirarubicin combined with hyaluronic acid) and Group B (pirarubicin alone). Patients' demographics, treatment efficacy on recurrence, visual analog scale score, and postoperative complications were evaluated and analyzed during observation.

RESULTS

After the first month of intravesical chemotherapy, a perceptible relief of pelvic pain and urinary symptoms was detectable in Group A when compared with Group B (Fig. 2; P = 0.04). From objective analysis, the clinicians observed a consistent better improvement in Group A than in Group B on clinical conditions (P = 0.02). Frequency, urgency, and odynuria are relieved effectively in Group A (21/64 32.9%) and in Group B (41/63 65.1%), with significant difference observed (P = 0.001). No statistical evidence of benefit was observed in terms of recurrence. No obvious hyaluronic acid-related adverse event was observed.

CONCLUSIONS

As compared to intravesical instillation of pirarubicin alone, the administration of pirarubicin combined with HA for prevention from postoperative recurrence was satisfactory and safe. The relief of pelvic pain and urinary symptoms is more rapid and more durable.

Chemical- and radiation-induced haemorrhagic cystitis: current treatments and challenges

To review the published data on predisposing risk factors for cancer treatment-induced haemorrhagic cystitis (HC) and the evidence for the different preventive and therapeutic measures that have been used in order to help clinicians optimally define and manage this potentially serious condition.

Despite recognition that HC can be a significant complication of cancer treatment, there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.

A systematic literature review was undertaken to evaluate the evidence for preventative measures and treatment options in the management of cancer treatment-induced HC.

There is a wide range of reported incidence due to several factors including variability in study design and quality, the type of causal agent, the grading of bleeding, and discrepancies in definition criteria.

The most frequently reported causal factors are radiotherapy to the pelvic area, where HC has been reported in up to 20% of patients, and treatment with cyclophosphamide and bacillus Calmette-Guérin, where the incidence has been reported as up to 30%.

Mesna (2-mercaptoethane sodium sulphonate), hyperhydration and bladder irrigation have been the most frequently used prophylactic measures to prevent treatment-related cystitis, but are not always effective.

Cranberry juice is widely cited as a preventative measure and sodium pentosanpolysulphate as a treatment, although the evidence for both is very limited.

The best evidence exists for intravesical hyaluronic acid as an effective preventative and active treatment, and for hyperbaric oxygen as an equally effective treatment option.

The lack of robust data and variability in treatment strategies used highlights the need for further research, as well as best practice guidance and consensus on the management of HC.

The role of sodium hyaluronate and sodium chondroitin sulphate in the management of bladder disease

Bladder epithelium is not only a simple defence against infections, but it is also a specialized tissue regulating complex bladder functions and playing an active role in the pathogenesis of many bladder diseases. There is strong evidence that different chronic inflammatory bladder diseases, such as recurrent urinary tract infection (UTI), chemical or radiation cystitis and painful bladder syndrome/interstitial cystitis (PBS/IC), can be pathophysiologically linked in the first step of the disease to the loss of the glycosaminoglycan (GAG) mucous layer independently of the original cause of the inflammatory process. The aim of this article is to review the current evidence on the clinic applications of GAGs in urology, with particular emphasis on the therapeutic use of hyaluronic acid (HA) and chondroitin sulphate (CS). A comprehensive electronic literature search was conducted in May 2011 using the Medline database. Three studies supported the decrease of the rate of recurrent UTIs by restoring the GAG layer, showing a significant reduction of UTI rates and a prolonged median time to recurrence after HA intravesical instillations in women with recurrent UTI. We provide higher level evidence by reporting a prospective, randomized, double-blind, placebo-controlled study on the use of intravesical HA and CS in women with recurrent UTIs. A significant reduction of 77% in the UTI rate per patient per year versus placebo was observed at the end of the study. Nine studies were published between 2002 and 2011 on the use of HA and CS to treat PBS/IC. Three of them evaluated the use of GAGs bladder instillation to prolong the effects of bladder hydrodistension. In the other six studies the efficacy of HA bladder instillations to reduce symptoms score was assessed. Preliminary studies support data on the role of HA-CS in detrusor overactivity, nonbacterial cystitis and urological malignancies. Few data are available regarding the mode of action of HA-CS or its effectiveness in the management of bladder diseases. The major issue in interpreting the available evidence regarding HA-CS is that most of the reported studies are nonrandomized and without a control arm. HA-CS may be considered for further studies, including randomized, controlled trials with adequate power.