Intravesical formalin for hemorrhagic cystitis: analysis of therapy

Pelvic Extirpative Surgery for the "End-Stage Irradiated Bladder"

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the "end-stage bladder" resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life.

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.

Heterogeneity in the pharmacological management of radiation-induced hemorrhagic cystitis

BACKGROUND

Radiation-induced hemorrhagic cystitis is a complication of pelvic radiotherapy, with an incidence of up to 5%. The resultant hematuria may be severe and refractory to conservative measures. Our objective was to describe the pattern of inpatient treatments among a cohort of patients with radiation-induced hemorrhagic cystitis requiring pharmacological management.

METHODS

We conducted a retrospective case series to identify all inpatient admissions at a single institution during which patients with radiation cystitis underwent pharmacological intervention for refractory hematuria between 2004 and 2019. Patient demographics, medical history, details of radiation therapy, and relevant admission data were collected. Details of treatment, including the use of pharmacotherapy and surgical treatment, were reviewed and summarized.

RESULTS

We identified 21 patients who were treated during 26 admissions. Most were male (91%) with a history of external beam radiation therapy (86%), primarily for prostate cancer (85%), and a median age of 73 (IQR: 67-85). Most patients received continuous bladder irrigation as the first intervention during their admission (65%), for a median duration of 40 hours (IQR: 25-59). Eleven separate pharmacologic agents were used, with variations in initial pharmacotherapy utilization over time. Most patients were treated with a combination of surgical and pharmacological interventions (85%). The median length of stay was 9 days (IQR: 5-17) and the 90-day readmission rate was 35%.

CONCLUSIONS

Pharmacologic treatment for refractory radiation-induced hemorrhagic cystitis is inconsistent and lacks evidence to support treatment strategies. Further work is needed to determine the optimal management for this morbid complication.

Utilizing Xenogeneic Cells As a Therapeutic Agent for Treating Diseases

The utilization of biologically produced cells to treat diseases is a revolutionary invention in modern medicine after chemically synthesized small molecule drugs and biochemically made protein drugs. Cells are basic units of life with diverse functions in mature and developing organs, which biological properties could be utilized as a promising therapeutic approach for currently intractable and incurable diseases. Xenogeneic cell therapy utilizing animal cells other than human for medicinal purpose has been studied as a new way of treating diseases. Xenogeneic cell therapy is considered as a potential regenerative approach to fulfill current unmet medical needs because xenogeneic cells could be isolated from different animal organs and expanded ex vivo as well as maintain the characteristics of original organs, providing a versatile and plenty cell source for cell-based therapeutics beside autologous and allogeneic sources. The swine species is considered the most suitable source because of the similarity with humans in size and physiology of many organs in addition to the economic and ethical reasons plus the possibility of genetic modification. This review discusses the old proposed uses of xenogeneic cells such as xenogeneic pancreatic islet cells, hepatocytes and neuronal cells as a living drug for the treatment of degenerative and organ failure diseases. Novel applications of xenogeneic mesenchymal stroma cells and urothelial cells are also discussed. There are formidable immunological barriers toward successful cellular xenotransplantation in clinic despite major progress in the development of novel immunosuppression regimens and genetically multimodified donor pigs. However, immunological barriers could be turn into immune boosters by using xenogeneic cells of specific tissue types as a novel immunotherapeutic agent to elicit bystander antitumor immunity due to rejection immune responses. Xenogeneic cells have the potential to become a safe and efficacious option for intractable diseases and hard-to-treat cancers, adding a new class of cellular medicine in our drug armamentarium.

Chronic Inflammation and Radiation-Induced Cystitis: Molecular Background and Therapeutic Perspectives

Radiation cystitis is a potential complication following the therapeutic irradiation of pelvic cancers. Its clinical management remains unclear, and few preclinical data are available on its underlying pathophysiology. The therapeutic strategy is difficult to establish because few prospective and randomized trials are available. In this review, we report on the clinical presentation and pathophysiology of radiation cystitis. Then we discuss potential therapeutic approaches, with a focus on the immunopathological processes underlying the onset of radiation cystitis, including the fibrotic process. Potential therapeutic avenues for therapeutic modulation will be highlighted, with a focus on the interaction between mesenchymal stromal cells and macrophages for the prevention and treatment of radiation cystitis.

A contemporary review about the management of radiation-induced hemorrhagic cystitis

PURPOSE OF REVIEW

There are various specific therapeutic intervention available to treat hemorrhagic cystitis, once emergency treatment has been carried out. The lack of prospective studies, because of the relative rarity of this condition, makes it difficult to hierarchize the therapeutic sequence. The present review presents and summarizes the literature published on radiation-induced hemorrhagic cystitis from April 2015, date of a precedent exhaustive review, to March 2018.

RECENT FINDINGS

During our period of interest, 13 clinical studies and two new clinical trials protocols were published. Most of the clinical studies were retrospective and presented data about hyperbaric oxygen (HBO) therapy, comforting its place as a well tolerated and effective first-line treatment. Other studies reported the outcomes of treatments with alum, formalin, silver nitrate, fulguration with laser or definitive surgery.

SUMMARY

Although authors seem to agree that formalin and surgery have their role as effective but potentially morbid last-line treatments, there is no consensus on primary approach to management of radiation-induced hemorrhagic cystitis beyond symptomatic measures. Several treatments have proven excellent response rates and few side effects. The results of on-going prospective studies on mesenchymal stromal cells or tacrolimus instillations are awaited, but the main discriminating factor to choose between treatments remains local availability.

[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.

Intravesical Administration of Xenogeneic Porcine Urothelial Cells Attenuates Cyclophosphamide-Induced Cystitis in Mice

The urothelium of the bladder, renal pelvis, ureter and urethra is maintained through the regulated proliferation and differentiation of urothelial stem and progenitor cells. These cells provide a rich source of a novel urothelial cell therapy approach that could be used to protect, regenerate, repair and restore a damaged urothelium. Urothelial injury caused by physical, chemical and microbial stress is the pathological basis of cystitis (bladder inflammation). The loss of urothelial integrity triggers a series of inflammatory events, resulting in pain and hematuria such as hemorrhage cystitis and interstitial cystitis. Here we investigate a novel cell therapy strategy to treat cystitis by protecting the urothelium from detrimental stresses through intravesically instilling porcine urothelial cells (PUCs) into the bladder. Using a chemical-induced urothelial injury mouse model of cyclophosphamide (CPP)-induced hemorrhagic cystitis, we determined how the intravesical instillation of PUCs could protect the urothelium from toxic attack from CPP metabolites. We show that intravesical PUC instillation protected the bladder from toxic chemical attack in mice receiving CPP with reduced inflammation and edema. Compared with the vehicle control mice, the proliferative response to chemical injury and apoptotic cells within the bladder tissues were reduced by intravesical PUC treatment. Furthermore, the urothelium integrity was maintained in the intravesical PUC-treated group. After xenogeneic PUCs were introduced and adhered to the mouse urothelium, immunological rejection responses were observed with increased neutrophil infiltration in the lamina propria and higher immune-related gene expression. Our findings provide an innovative and promising intravesical PUC cell therapy for cystitis with urothelial injury by protecting the urothelium from noxious agents.

Hemorrhagic cystitis after hematopoietic stem cell transplantation: A challenge for the pediatric urologist

OBJECTIVE

Hemorrhagic cystitis (HC) is a serious event that can occur after hematopoietic stem cell transplantation (HSCT). Treatment goals are primarily to preserve life, and then the functionality of the bladder. There is no standard therapeutic approach for HC. Described treatment options provide low success rates and are related to potential life-threatening side effects. The aim of this study was to describe our experience in treatment of HC following HSCT.

PATIENTS AND METHODS

This was a retrospective study of patients with HC treated at our institution between January 2010 and October 2016. We analyzed demographics, underlying diagnosis, and treatment modalities.

RESULTS

We treated 39 patients with HC. Mean age was 9.4 years (SD 4.20) and 64% were males. Acute leukemia was the most common underlying diagnosis in 27 (69%). Mean time from HSCT to HC onset was 55.46 days (SD 112.35). HC grades were: I (3), II (21), III (8), and IV (7). BK-viuria was present in 34 patients (87.2%). Non-invasive treatment was performed in 28 patients (71.8%). The remaining 11 (28.2%) required urological intervention (all high-grade), consisting of bladder irrigation in all of these. Additional treatments consisted of: intravesical cidofovir (4), intravesical sodium hyaluronate (5), cystoscopy and clot evacuation (4), selective angioembolization (2), percutaneous nephrostomy (1), and open extraction of bladder clots and cutaneous cystotomy (1). Overall, eight patients (20.5%) died as a result of the malignancy (3 in the urological intervention group), and of these four had active HC at death. Mean follow-up was 36.2 months (SD 24.9).

CONCLUSION

HC is associated with high morbidity and mortality. Treatment should be individualized and designed to prioritize survival. However, bladder function should be preserved for the future.

Intravesical formalin for hemorrhagic cystitis: A contemporary cohort

INTRODUCTION

Hemorrhagic cystitis presents a difficult clinical challenge, yet data regarding treatment options is sparse. Here, we sought to evaluate outcomes of a contemporary cohort of patients treated with intravesical formalin for hemorrhagic cystitis.

METHODS

We identified a retrospective cohort of eight patients managed with formalin for hemorrhagic cystitis from 2000-2014. All patients failed prior measures, including bladder irrigation, clot evacuation, and other intravesical agents. Treatment success was defined as hematuria resolution during the given hospitalization without use of additional invasive therapies. We also evaluated treatment complications and additional treatments following hospital dismissal.

RESULTS

Etiology of cystitis was radiation for malignancy in all cases. The formalin concentration ranged from 1-4%, with escalation used in treatment failures. Five patients (62.5%) received a single dose of 1% formalin, two patients received two doses, and one patient received three doses. Notably, intraoperative cystography identified vesicoureteral reflux (VUR) in 50.0% of patients. Six patients (75.0%) achieved treatment success, with a median time to resolution of four days (range 1-17 days). Of those refractory to formalin, one was managed with indwelling nephrostomy tubes and one underwent cystectomy. Median followup was eight months. Of the responders, two eventually required cystectomy, one for recurrent hematuria and one for recalcitrant bladder neck contracture and bladder dysfunction. The remaining four patients (50%) required no additional therapy.

CONCLUSIONS

Formalin remains an important tool for treating refractory hemorrhagic cystitis, with roughly 75.0% of patients requiring no additional therapy prior to hospital discharge. Notably, there is a risk of bladder dysfunction following formalin.

A retrospective study of treatment and prophylaxis of ifosfamide-induced hemorrhagic cystitis in pediatric and adolescent and young adult (AYA) patients with solid tumors

OBJECTIVE

Ifosfamide (IFO) is considered an essential drug for the treatment of pediatric, adolescent and young adult patients with solid tumors. Hemorrhagic cystitis (HC) is one of the dose-limiting toxicity of IFO. However, there are insufficient evidence for risk factor and supportive care of IFO-induced HC.

METHODS

In this retrospective study, patients (<30-year-old) with malignant solid tumors who had been treated with IFO-based chemotherapy, were categorized according to the presence or absence of HC, and were analyzed possible risk factors for IFO-induced HC. In our institution, continuous hydration to increase urine output and intravenous 2-mercaptethane sulfonate (mesna) are used for prophylaxis of IFO-induced HC. Increased hydration and dosage of mesna are administered to patients who develop IFO-induced HC; they also receive 24-h continuous infusion of mesna in subsequent treatment cycles.

RESULTS

Nine treatment regimens were used in the 70 study patients. The range of daily IFO dosage was 1.2-3.0 g/m(2). HC occurred in 14/425 IFO-based chemotherapy cycles (3.3%). The daily IFO dosages (mean ± SD) in patients with or without HC were 2.23 ± 0.58 g/m(2) and 1.85 ± 0.50 g/m(2), respectively (P = 0.006). Only one of the nine patients who developed IFO-induced HC had experienced this complication in a subsequent cycle of treatment.

CONCLUSION

The incidence of IFO-induced HC may be associated with the dosage of IFO. When administering IFO higher than 2.0 g/m(2)/day, the volume of hydration, dosage of mesna and duration of mesna infusion should be increased to prevent HC.

Challenges and Opportunities in Radiation-induced Hemorrhagic Cystitis

As diagnosis and treatment of cancer is improving, medical and social issues related to cancer survivorship are becoming more prevalent. Hemorrhagic cystitis (HC), a rare but serious disease that may affect patients after pelvic radiation or systemic chemotherapy, has significant unmet medical needs. Although no definitive treatment is currently available, various interventions are employed for HC. Effects of nonsurgical treatments for HC are of modest success and studies aiming to control radiation-induced bladder symptoms are lacking. In this review, we present current and advanced therapeutic strategies for HC to help cancer survivors deal with long-term urologic health issues.

Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitis due to carcinoma cervix: a study from a tertiary care hospital in South India

BACKGROUND

To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy.

METHODS

Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis.

RESULTS

Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature.

CONCLUSION

In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, cost-effective approach with good quality of life and early return to normal activity.

Advances in Therapeutic Development for Radiation Cystitis

Radiation treatment for pelvic malignancies is typically associated with radiation injury to urinary bladder that can ultimately lead to radiation cystitis (RC). The late sequelae of radiation therapy may take many years to develop and include bothersome storage symptoms such as hematuria, which may be life-threatening in severe cases of hemorrhagic cystitis. Although no definitive treatment is currently available, various interventions are used for radiation and hemorrhagic cystitis including blood transfusion, bladder irrigation, intravesical instillation of substances such as alum, silver nitrate, prostaglandins or formalin, and fulguration of intravesical bleeding sites and surgery options such as supravesical urinary diversions and cystectomy. Effects of non-surgical treatments for radiation and hemorrhagic cystitis are of modest success and studies are lacking to control the effects caused by RC. When such measures have proven ineffective, use of bladder botulinum toxin injection has been reported. New therapy, such as intravesical immunosuppression with local tacrolimus formulation is being developed for the treatment of radiation hemorrhagic cystitis.

Intractable hemorrhagic cystitis after hematopoietic stem cell tranplantation--is there a role for early urinary diversion in children?

PURPOSE

Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy.

MATERIALS AND METHODS

Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis.

RESULTS

Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement.

CONCLUSIONS

Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.

Management of radiation cystitis

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

Pediatric hemorrhagic cystitis

PURPOSE

To review the current literature as it pertains to hemorrhagic cystitis (HC) in the pediatric bone-marrow transplant (BMT) population. By reviewing the pathophysiology of the disease, preventive methods, and therapeutic options, urologists may be better equipped to manage this challenging clinical scenario.

MATERIALS AND METHODS

The HC literature was reviewed using a MEDLINE/PubMed literature search, specifically focusing on the pediatric BMT population as it pertains to the incidence, pathophysiology, prevention, and treatment of HC.

RESULTS

Conservative estimates of HC incidence in recent retrospective studies of pediatric BMT populations still approach 10-20%. Several high-volume pediatric BMT centers have reported contemporary data on their experience with HC providing increased insight into incidence and pathophysiology. Accumulating evidence linking BK virus to HC is a significant development warranting further investigation. Other contributing agents/risk factors need identification in the likely multifactorial etiology of HC. Preventive and therapeutic strategies have made modest advances, but certainly need further validation with prospective randomized studies.

CONCLUSIONS

Pediatric BMT patients are susceptible for HC development despite preventive measures and improved insight into the pathophysiology. Unfortunately, there are no evidence-based treatment guidelines for this difficult clinical issue that frequently requires prolonged care and multiple treatment modalities necessitating judicious patience in the application of more aggressive interventions.

Late effects on the urinary bladder in patients treated for cancer in childhood: a report from the Children's Oncology Group

Childhood cancer survivors who have had pelvic or central nervous system surgery or have received alkylator-containing chemotherapy or pelvic radiotherapy as part of their cancer therapy may experience urinary bladder late effects. This article reviews the medical literature on long-term bladder complications in survivors of childhood cancer and outlines the Children's Oncology Group Long-Term Follow-up (COG LTFU) Guidelines related to bladder function. An overview of the treatment of bladder late effects and recommended counseling for survivors with these complications are presented.

Surgical Complications of Childhood Tumors

Most childhood tumors will first present to a physician; some tumors will present in an atypical manner and may mimic a surgical condition. The diagnosis may be missed if the surgeon is not aware of the possibility of cancer. A very great number of rare presentations of childhood cancer have been described in the literature. It is important that the surgeon who is not experienced in the management of childhood cancer is aware that an apparently benign condition could be a manifestation of an underlying malignancy [71, 83] (Table 22.1).

Two percent formalin retention enemas for hemorrhagic radiation proctitis: a preliminary report

PURPOSE

The short-term safety and efficacy of 2 percent formalin administered as a retention enema for hemorrhagic radiation proctitis was studied.

METHODS

A group of 24 patients with hemorrhagic radiation proctitis who received radical radiotherapy were administered 2 percent formalin as a retention enema and the treatment was followed up from 1 to 29 (mean, 15.34) weeks. The enema was performed on an outpatient basis under sedation with pentazocine and promethazine with a retention time of two minutes. The symptoms and proctoscope findings were graded and converted into a numeric score, ranging from 1 to 4. The mean improvements in scores before treatment and after the last follow-up were analyzed for statistical significance by using the paired t-test.

RESULTS

There was complete cessation of bleeding in 47.8 percent of patients and very negligible bleeding in 30.4 percent. A total of 78.2 percent responded positively to treatment with 2 percent formalin retention enema. More than one application was required in 34.7 percent of the patients. The procedure was well tolerated and most of the side effects were mild. Side effects were diarrhea in 23.5 percent, abdominal pain and tenesmus in 8.8 percent, and fever with vomiting in 2.9 percent of patients. There was a statistically significant reduction in bleeding and proctoscopy scores (P<0.01). None of the patients in this study required surgery to palliate their symptoms.

CONCLUSIONS

Two percent formalin when given as a retention enema is a safe, inexpensive, and effective intervention for hemorrhagic radiation proctitis. Any trained health worker using simple precautions can perform this procedure. The long-term efficacy and safety of 2 percent formalin retention enemas need further assessment with randomized, controlled trials.

Oncologic Emergencies

It has been estimated that genitourinary malignancies will account for 25% of new cancer diagnoses in the United States in 2005 (Jemal et al. 2005). While the incidence of many of these malignancies has increased over the past two decades, the mortality rates appear to be decreasing. Early cancer detection combined with improvements in surgical and nonsurgical oncologic therapy account for these trends. Although not common, newly diagnosed cancer patients occasionally present in an emergent, life-threatening manner that warrants immediate medical or surgical intervention. As the prevalence of genitourinary malignancies continues to expand, additional patients can be expected to develop disease or treatment-related complications. This chapter will serve to review the diagnosis and management of oncologic emergencies as they pertain to the urologist.

Formalin treatment of refractory hemorrhagic cystitis

Severe hemorrhagic cystitis can be a devastating complication of chemotherapy. Intravesical formalin may obviate the need for radical surgery in the face of failure of other conservative measures. Open instillation is favored in order to reduce the risk of complications.

MEDICAL AND SURGICAL PALLIATIVE CARE OF PATIENTS WITH UROLOGICAL MALIGNANCIES

PURPOSE

Urological malignancies are relatively common and patients often live many years with disease. There are many effective medical and surgical palliative treatments, although few comprehensive guidelines have been published. We reviewed the various palliative treatments available for the 3 most common urological malignancies, namely prostate cancer, bladder cancer and renal cancer.

MATERIALS AND METHODS

A literature search of the last 15 years was performed using MEDLINE/PubMed. In addition, relevant journals were targeted for specific information related to this review. Our clinical experience was combined with the current literature to create guidelines for palliative care.

RESULTS

Several effective treatments are available for the palliative care of patients with prostate, bladder or renal cancer. Options in palliative care are varied with regard to invasiveness, morbidity, risks and benefits. The algorithms described provide a framework to a sequential approach to achieving palliation. Urologists are central to initiating care and referrals to improve outcomes in these patients.

CONCLUSIONS

Palliative care includes disease directed treatment as well as functional, psychosocial and spiritual support. Disease directed therapy and palliative care should be provided simultaneously throughout illness. Improved quality of care and quality of life as well as physician satisfaction are frequent outcomes of this approach. Supportive care begins at initial diagnosis and it should be flexible to meet the changing needs of patients with cancer and their families.

Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients

PURPOSE

This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis.

METHODS

All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas.

RESULTS

The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent).

CONCLUSION

Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.

Intravesical lidocaine for formalin-induced suprapubic pain: Case report

This case report describes the management of intravesical formalin induced suprapubic pain using intravesical lidocaine.

Conservative therapies for hemorrhagic radiation proctitis: a review

Chronic radiation proctitis represents a challenging condition seen with increased frequency due to the common use of radiation for treatment of pelvic cancer. Hemorrhagic radiation proctitis represents the most feared complication of chronic radiation proctitis. There is no consensus for the management of this condition despite the great number of clinical approaches and techniques that have been employed. Rectal resection represents an available option although associated with high morbidity and risk of permanent colostomy. The effectiveness of nonoperative approaches remains far from desirable, and hemorrhagic recurrence represents a major drawback that leads to a need for consecutive therapeutic sessions and combination of techniques. We conducted a critical review of published reports regarding conservative management of hemorrhagic chronic radiation proctitis. Although prospective randomized trials about hemorrhagic radiation proctitis are still lacking, there is enough evidence to conclude that topical formalin therapy and an endoscopic approach delivering an argon plasma coagulation represent available options associated with elevated effectiveness for interruption of rectal bleeding in patients with chronic radiation proctitis.

Formaldehyde application for haemorrhagic radiation-induced proctitis: a clinical and histological study

OBJECTIVES

Haemorrhagic radiation-induced proctitis is a serious complication of radiotherapy of pelvic organs. In severe cases, massive haemorrhage may necessitate hospitalization and repeated transfusions. Application of formaldehyde under direct vision is one of the most efficient treatments. The aim of this study was to evaluate the results of this treatment as well as the histological changes induced by formaldehyde on the rectal mucosa.

MATERIAL AND METHODS

From January 1991 to September 2001, 13 patients who presented a haemorrhagic radiation-induced proctitis have been treated in our outpatient clinic with 4% formaldehyde cotton soaked applications. They were followed up to one year after the treatment. Endoscopic biopsies were performed before, immediately after the application, 1 month later, as well as at the one-year follow-up.

RESULTS

In eight cases bleeding stopped after the first application. In two patients a second application was necessary to control the haemorrhage and in two other patients bleeding ceased definitively after the fourth application. Follow-up evaluation at 12 months showed no sign of acute proctitis or rebleeding. One asymptomatic patient had a mild stenosis of the rectum. Baseline biopsies showed signs of acute inflammation. Those performed after the application of formaldehyde showed fresh thromboses of the vessels of the mucosa. Biopsies at 1 month and 1 year showed only chronic changes secondary to the radiotherapy.

CONCLUSION

Local application of 4% formaldehyde for the treatment of haemorrhagic radiation-induced proctitis gives good results, is well tolerated and easy to perform. Formaldehyde applied selectively causes thromboses of the bleeding vessels, without deep lesions or extended necrosis.

Pharmacotherapy for chronic hemorrhagic radiation proctitis

Endoscopic thermal therapy and formalin are being increasingly recommended for the treatment of chronic hemorrhagic radiation proctitis. It may be too early, however, to discard pharmacologic agents from the management process, especially in medical institutions where specialized equipment is unavailable. We prospectively assessed the effectiveness of medical therapy in 14 consecutive patients with chronic hemorrhagic radiation proctitis from July 1999 to June 2001. All 14 subjects were women (mean age 56 years), 13 of whom had had radiotherapy for cancer of the cervix. The median time to onset of symptoms following irradiation was 16 months. Six patients had a hemoglobin level of < 8 g/dl, and blood transfusion was required in 11 patients. In five patients (36%) initially treated with hydrocortisone enemas prior to referral, this treatment continued; and the remaining nine patients were commenced on sucralfate enemas. Two patients given rectal hydrocortisone continued to bleed and were treated with sucralfate enemas and topical formalin, respectively. Rectal sucralfate suspension effectively procured symptomatic alleviation in all 11 patients. Rectal bleeding recurred in two patients who had been managed exclusively with hydrocortisone and sucralfate enemas, respectively, over a mean follow-up of 6 months. Both patients were managed with topical formalin, which controlled their symptoms. Even though the number of subjects in this study is small, sucralfate enema can be recommended as an effective first-line agent for managing patients with chronic hemorrhagic radiation proctitis. The use of more specialized therapy can therefore be reserved for cases where primary treatment failure occurs with sucralfate therapy.

Intravesicle formalin instillation with a modified technique for controlling haemorrhage secondary to radiation cystitis

OBJECTIVE

Intractable haemorrhage, secondary to radiation cystitis, is a serious complication of radiotherapy for pelvic malignancies. Formalin instillation is often effective for intractable haemorrhage unresponsive to other agents, but carries the risk of significant morbidity. The placement of formalin-soaked pledgets is a modified technique for the treatment of this complication. We compare the effectiveness and complications of both techniques.

METHODS

Eleven patients with intractable haemorrhage secondary to radiation cystitis were treated by intravesicle 4% formalin instillation [Group I] and eight were treated by the endoscopic placement of 10% formalin-soaked pledgets on the bleeding points for 15 minutes [Group II].

RESULTS

Cessation of bleeding was 9 of 11 [82%] and 6 of 8 [75%] in Group I and Group II, respectively. One patient in Group II required two treatments, due to recurrent haemorrhage. Four major and several minor complications were found in Group I, and only three minor complications were found in Group II.

CONCLUSION

Formalin instillation is effective in controlling severe bladder haemorrhage after radiation of the pelvis, but the complications secondary to the fixative properties are severe. Topical application of formalin-soaked pledgets is as effective in controlling the haemorrhage as conventional intravesicle formalin instillation, with fewer complications. This technique should be the initial treatment for this complication.

Encouraging results in the treatment of haemorrhagic cystitis with estrogen - report of 10 cases and review of the literature

Haemorrhagic cystitis (HC) after allogeneic haematopoietic stem cell transplantation (HSCT) or high-dose cyclophosphamide (CP) chemotherapy is a severe side-effect and can cause significant morbidity and mortality. In this report, we describe the clinical courses of 10 patients with HC and review the literature. The patients were treated with oral conjugated estrogen in an attempt to improve severe haemorrhagic cystitis. In seven patients positive effects were seen, haematuria resolved in all, but residual symptoms of dysuria remained for longer periods. In one patient application of estrogen was interrupted because of hepatotoxicity. Two patients failed all treatment modalities including oral estrogen because of terminal illness. We conclude that in the management of HC the administration of oral conjugated estrogen should be considered.

Intrarectal formalin application, an effective treatment for grade III haemorrhagic radiation proctitis

Haemorrhagic radiation proctitis (HRP) is infrequently seen amongst the patients who are either undergoing or have undergone radiotherapy to the pelvis. We treated 16 documented cases of HRP, who did not respond to conventional steroid retention enemas, with 4% formalin application. It was observed that the rectal bleeding was controlled completely in 81% cases in median follow up of 11 months (range 6-17 months) and diversion colostomy could be avoided in all the cases. The effectiveness of local formalin application in severe HRP is described in this article.

Hemorrhagic cystitis in bone marrow transplantation

OBJECTIVES

Patients undergoing bone marrow transplantation are at risk for hemorrhagic cystitis despite appropriate preventive measures. This complication could have an impact on patient survival and other outcome variables.

METHODS

A retrospective study of patients subjected to bone marrow transplantation was conducted to determine risk factors for hemorrhagic cystitis and evaluate the impact of hemorrhagic cystitis on certain outcome variables. Patients who experienced hemorrhagic cystitis received various forms of therapy, at the discretion of the treating physician.

RESULTS

Hemorrhagic cystitis occurred more frequently in younger patients and those undergoing allogeneic transplantation. The occurrence of hemorrhagic cystitis was associated with increased hospital costs, length of hospitalization, and mortality. Gender, race, type of malignancy, other pretransplantation comorbidity, and the occurrence of other peritransplantation complications were not associated with occurrence of hemorrhagic cystitis.

CONCLUSIONS

Hemorrhagic cystitis is a significant complication of bone marrow transplantation, which influences economic and survival outcome. Since the number of bone marrow transplants being performed is increasing, urologists should be prepared to play an active role in treating patients who experience this complication.

Oral conjugated estrogen therapy for treatment of hemorrhagic cystitis

We report 7 cases of severe hemorrhagic cystitis that required repeated transfusions, surgical intervention and oral conjugated estrogens. Of these 7 cases hematuria resolved completely in 5 during estrogen therapy and decreased sufficiently in 1 to preclude further transfusion. We found conjugated estrogens to be an effective, simple, inexpensive, well tolerated and readily available treatment for hemorrhagic cystitis.

Cutaneous vesicostomy with direct intravesical application of formalin: management of severe vesical hemorrhage resulting from high dose cyclophosphamide in boys

A severe form of hemorrhagic cystitis occurs when high doses of cyclophosphamide are administered before bone marrow transplantation. Severe vesical bleeding in male children is difficult to manage because the small urethra precludes the use of large catheters for bladder irrigation and clot removal. We report on the use of cutaneous vesicostomy with the instillation of 4% formalin to control bleeding in 3 boys.

Urologic complications of high-dose chemotherapy and bone marrow transplantation

OBJECTIVE

This study reviews the incidence and management of cyclophosphamide-induced hemorrhagic cystitis in a group of patients who received high-dose chemotherapy and bone marrow transplantation.

METHODS

The records of 217 consecutive patients undergoing bone marrow transplantation were reviewed. The incidence, degree, and management of hematuria in this group of pancytopenic and immunocompromised patients were recorded.

RESULTS

Despite prophylaxis, cystitis developed in 58 of these 217 patients (27%). In 12 patients (6%) the cystitis was severe. These patients had gross hematuria, clot retention, and drop in hematocrit necessitating blood transfusion. These patients were managed with continuous bladder irrigation, alum irrigation, and when less aggressive approach was unsuccessful, with intravesical formalin instillation. Alum irrigation was used in 5 patients, and was successful in only 1 patient. Six patients required intravesical formalin instillation to control the hematuria. Formalin solution 2-5% was instilled initially. When lower-concentration formalin failed, 5-10% formalin was used progressively.

CONCLUSIONS

Patients with bone marrow transplantation in whom severe hemorrhagic cystitis develops should be managed aggressively early. Intravesical formalin appears to be the most effective regimen in controlling profuse, persistent hematuria.