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Li KD, Jones CP, Hakam N, Erickson BA, Vanni AJ, Chancellor MB, Breyer BN. Haemorrhagic cystitis: a review of management strategies and emerging treatments. BJU Int 2023; 132:631-637. [PMID: 37501638 DOI: 10.1111/bju.16140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Haemorrhagic cystitis (HC) is characterised by persistent haematuria and lower urinary tract symptoms following radiotherapy or chemotherapy. Its pathogenesis is poorly understood but thought to be related to acrolein toxicity following chemotherapy or fibrosis/vascular remodelling after radiotherapy. There is no standard of care for patients with HC, although existing strategies including fulguration, hyperbaric oxygen therapy, botulinum toxin A, and other intravesical therapies have demonstrated short-term efficacy in cohort studies. Novel agents including liposomal tacrolimus are promising targets for further research. This review summarises the incidence and pathogenesis of HC as well as current evidence supporting its different management strategies.
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Affiliation(s)
- Kevin D Li
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Charles P Jones
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Nizar Hakam
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | | | - Alex J Vanni
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Michael B Chancellor
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oaks, MI, USA
| | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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2
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Dubois A, Freton L, Richard C, Haudebert C, Jezequel M, Hascoet J, Peyronnet B. [Genitourinary complications after pelvic radiotherapy: Diagnosis and management]. Prog Urol 2023; 33:563-571. [PMID: 38783761 DOI: 10.1016/j.purol.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 05/25/2024]
Abstract
OBJECTIVE The purpose of this review was to present the different genitourinary complications following pelvic radiotherapy as well as their assessment and treatments. METHODS A review of literature was conducted using Medline/Pubmed database without period restriction. In order to write this article, we also use the 2016 AFSOS, SFRO and AFU recommendations. RESULTS On the one hand, early side effects are common and mild. The symptomatic treatments available generally provide effective relief to patients. On the other hand, late adverse effects need long and complex care. Its side effects alter the quality of life and can be life-threatening. The effects of radiotherapy are irreversible. Except hyperbaric oxygen therapy and hyaluronic acid/chondroitin sulfate instillations, treatments remain symptomatic. Urethrovesical fibroscopy is essential in cases of gross hematuria, and urodynamic assessment (or videourodynamic) can be used in cases of severe vesicosphincter disorders. Pharmacological treatments are less effective than in non-radiation patients, and the morbidity of surgical treatments is higher in this population. CONCLUSION Genitourinary complications after pelvic radiotherapy are frequent and mild in the early phase but rare and severe in the late phase. Their management is based on a vast diagnostic and therapeutic arsenal, but the treatments are only symptomatic, and the sequelae of radiotherapy remains, to date, irreversible.
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Affiliation(s)
- A Dubois
- Service d'urologie, CHU de Rennes, Rennes, France.
| | - L Freton
- Service d'urologie, CHU de Rennes, Rennes, France
| | - C Richard
- Service d'urologie, CHU de Rennes, Rennes, France
| | - C Haudebert
- Service d'urologie, CHU de Rennes, Rennes, France
| | - M Jezequel
- Service d'urologie, CHU de Rennes, Rennes, France
| | - J Hascoet
- Service d'urologie, CHU de Rennes, Rennes, France
| | - B Peyronnet
- Service d'urologie, CHU de Rennes, Rennes, France
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Hughes C, Harris A, Watkins B, Qayed M, Parikh S, Horwitz E, Stenger E, Williams KM, Schoettler ML. Severe refractory hemorrhagic cystitis after hematopoietic cell transplantation responds to recombinant human keratinocyte growth factor-Case report and review of the literature. Pediatr Blood Cancer 2023; 70:e30606. [PMID: 37533091 DOI: 10.1002/pbc.30606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Catherine Hughes
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Edwin Horwitz
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
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Jefferson FA, Linder BJ. Hemorrhagic Cystitis: Making Rapid and Shrewd Clinical and Surgical Decisions for Improving Patient Outcomes. Res Rep Urol 2023; 15:291-303. [PMID: 37404838 PMCID: PMC10317550 DOI: 10.2147/rru.s320684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
Hemorrhagic cystitis (HC) can be one of the most challenging clinical scenarios for urologists to manage. It most commonly occurs as a toxicity of pelvic radiation therapy or in patients treated with the oxazaphosphorine class of chemotherapy. Successful management of HC necessitates a stepwise approach with a thorough understanding of the various treatment options. Once ensuring hemodynamic stability, conservative management includes establishing bladder drainage, manual clot evacuation, and continuous bladder irrigation through a large-bore urethral catheter. If gross hematuria persists, operative cystoscopy with bladder clot evacuation is often required. There are multiple intravesical options for treating HC, including alum, aminocaproic acid, prostaglandins, silver nitrate, and formalin. Formalin is an intravesical option that has caustic effects on the bladder mucosa and is most often reserved as a last-line intravesical treatment. Non-intravesical management tools include hyperbaric oxygen therapy and oral pentosan polysulfate. If needed, nephrostomy tube placement or superselective angioembolization of the anterior division of the internal iliac artery can be performed. Finally, cystectomy with urinary diversion is a definitive, albeit invasive, treatment option for refractory HC. While there is no standardized algorithm, treatment modalities typically progress from less to more invasive. Clinical judgement and shared decision-making with the patient are required when choosing therapies for managing HC, as success rates are variable and some treatments may have significant or irreversible effects.
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Wang Y, Zhu Y, Xu X. Advances in the management of radiation-induced cystitis in patients with pelvic malignancies. Int J Radiat Biol 2023; 99:1307-1319. [PMID: 36940182 DOI: 10.1080/09553002.2023.2181996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 03/21/2023]
Abstract
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.
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Affiliation(s)
- Yimin Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yan Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoting Xu
- Department of Radiation Oncology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Safety and efficacy of intravesical epinephrine instillation in patients with intractable lower urinary tract hematuria - A novel approach. Urology 2023:S0090-4295(23)00155-3. [PMID: 36805415 DOI: 10.1016/j.urology.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/17/2023] [Accepted: 02/05/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVES To treat intractable hematuria with intravesical instillation of epinephrine. METHODS Sixty patients were treated with intravesical instillation of epinephrine at Mackay Memorial Hospital. The control group was composed of 60 patients who were treated with standard-of-care cystoscopic electrocautery fulguration. Under general anesthesia, epinephrine-treated group were injected with 150 mL of diluted epinephrine (1:10,000) through cystoscopy, followed by bladder irrigation with 1:100,000-diluted epinephrine at the ward. Successful hemostasis was defined as hematuria resolution within 1 month post-treatment without additional invasive procedures. RESULTS In the 60 patients who underwent intravesical instillation of epinephrine, radiation cystitis was the most common etiology (65.0%). Fifty-two patients (86.7%) required no additional therapy within 1 month after one course of intravesical epinephrine instillation treatment compared with 28 patients (46.7%) in the electrocautery fulguration-control group (p < 0.001). We observed a significant decrease in both the median length of hospitalization (p = 0.049) and the need for additional invasive procedures (p < 0.001) in the epinephrine group. In addition, cardiopulmonary monitoring of mean blood pressure, mean heart rate, and mean respiratory rate demonstrated no significant differences after epinephrine treatment. CONCLUSIONS In this study, intravesical instillation of epinephrine was an innovative method of hemostasis for intractable lower urinary tract hematuria with a success rate of 86.7%, compared to 46.7% in the control group, and significantly reduced the number of additional procedures required and the length of hospitalization. It was well tolerated by all patients, and was a safe and effective treatment modality for intractable hematuria or bladder hemorrhage.
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Wallace BK, Gillespie AM, Moran GW, Smigelski MB, Anderson CB. Heterogeneity in the pharmacological management of radiation-induced hemorrhagic cystitis. Urol Oncol 2022; 40:540.e11-540.e17. [PMID: 36229357 DOI: 10.1016/j.urolonc.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/28/2022] [Accepted: 09/11/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Brendan K Wallace
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Anton M Gillespie
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - George W Moran
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Michael B Smigelski
- Department of Urology, Columbia University Irving Medical Center, New York, NY
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Wu R, Shang Y, Liu X, Chen W, Yi S. Removal of large fibrotic bladder blood clots using prostatic tissue morcellator under real-time ultrasound guidance. Front Surg 2022; 9:889529. [PMID: 36132210 PMCID: PMC9483016 DOI: 10.3389/fsurg.2022.889529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Large fibrotic bladder blood clots are difficult to treat via conventional methods. Hence, we investigated the safety and reliability of real-time ultrasound guidance combined with prostate tissue morcellator in the removal of large fibrotic bladder blood clots in this study. Methods We chose 9 patients with large fibrotic bladder blood clots who were treated in our department from January 2019 to December 2020. Under the condition that conventional methods were ineffective in removing the bladder blood clot, real-time ultrasound guidance combined with a prostatic tissue morcellator was used to remove the large fibrotic bladder blood clot through the steps of positioning, breaking, adjusting repositioning and recrushing. After removal, the bipolar electrocautery was replaced to stop bleeding of the bladder mucosa. Results All patients successfully underwent the operation. After the blood clot was removed, the bladder mucosa was examined. There was no damage to the bladder mucosa or muscle layer. The urine was clear at the end of the procedure with slow irrigation, and no bleeding was found again. Conclusion Real-time ultrasound guidance combined with a prostate tissue morcellator was a safe, effective and quick method for the removal of large fibrotic bladder blood clots.
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Affiliation(s)
- Ronghua Wu
- Department of Urology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Yonggang Shang
- Reproductive Medicine Center, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xing Liu
- Department of Urology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Wei Chen
- Department of Urology, Xinqiao Hospital of Army Medical University, Chongqing, China
- Correspondence: Chen-Wei Yi-Shanhong
| | - Shanhong Yi
- Department of Urology, Xinqiao Hospital of Army Medical University, Chongqing, China
- Correspondence: Chen-Wei Yi-Shanhong
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Perry C, Kimble R. Refractory bladder haemorrhage managed with cystoscopic diathermy in a patient with Ataxia-Telangiectasia and intercurrent BK polyomavirus infection. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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Marchioni M, DE Francesco P, Campi R, Carbonara U, Ferro M, Schips L, Gomez Rivas J, Papalia R, Scarpa RM, Esperto F. Current management of radiation cystitis after pelvic radiotherapy: a systematic review. Minerva Urol Nephrol 2021; 74:281-291. [PMID: 34714035 DOI: 10.23736/s2724-6051.21.04539-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION We aimed to summarize current literature about radiation cystitis treatments, providing physician of a summary of current management options. EVIDENCE ACQUISITION A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in March 2021. PRISMA guidelines were followed. Population consisted of patients with a diagnosis of radiation cystitis after pelvic radiotherapy (P). We focused our attention on different treatments, such as conservative or surgical one (I). Single or multiple arms studies were deemed eligible with no mandatory comparison (C). Main outcomes of interest were symptoms control and adverse events rates (O). EVIDENCE SYNTHESIS The search identified 1,194 records. Of all, four studies focused on the use of hyperbaric oxygen therapy showing complete response rates ranging from 52 to 87% approximately. Oral administration of cranberry compounds was investigated in one study showing no superiority to placebo. Intravesical instillation of different compounds were investigated in five studies showing the highest complete response rates after alum (60%) and formalin administration (75%). Endoscopic conservative surgical treatments (fibrin glue or vaporization) also showed 75% complete response rates. In patients who did not respond to conservative treatments robotic cystectomy is feasible with overall complication rates of about 59.3% at 90 days. CONCLUSIONS Radiotherapy induced cystitis is an under-reported condition after pelvic radiotherapy. Several treatments have been proposed, but in up to 10% of cases salvage cystectomy is necessary. A stepwise approach, with progressive treatment aggressiveness is recommended.
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Affiliation(s)
- Michele Marchioni
- Unit of Urology, Department of Medical, Oral and Biotechnological Sciences, SS. Annunziata Hospital, G. d'Annunzio University, Chieti, Italy -
| | - Piergustavo DE Francesco
- Unit of Urology, Department of Medical, Oral and Biotechnological Sciences, SS. Annunziata Hospital, G. d'Annunzio University, Chieti, Italy
| | - Riccardo Campi
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Umberto Carbonara
- Department of Emergency and Organ Transplantation-Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Matteo Ferro
- Department of Urology, IRCSS European Institute of Oncology (IEO), Milan, Italy
| | - Luigi Schips
- Unit of Urology, Department of Medical, Oral and Biotechnological Sciences, SS. Annunziata Hospital, G. d'Annunzio University, Chieti, Italy
| | - Juan Gomez Rivas
- Department of Urology, La Paz University Hospital, Madrid, Spain
| | - Rocco Papalia
- Department of Urology, Campus Bio-Medico University, Rome, Italy
| | - Roberto M Scarpa
- Department of Urology, Campus Bio-Medico University, Rome, Italy
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Baboudjian M, Fourmarier M, Clement C, Cherasse A, Graziana JP, Bentaleb Y, Rouscoff Y, Ducrocq S, Gondran-Tellier B, Saussine C. Intravesical instillation of high molecular weight sodium hyaluronate in radiation-induced cystitis: a prospective pilot study. World J Urol 2021; 40:141-146. [PMID: 34550425 DOI: 10.1007/s00345-021-03837-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To assess the efficacy and safety of intravesical instillation of high molecular weight sodium hyaluronate (HMW-HA) for the treatment of radiation-induced cystitis. METHODS This prospective cohort study was conducted in seven centers in France. Eligible patients with radiation-induced cystitis were recruited between April 2020 and March 2021. A sterile disposable 50 ml prefilled solution containing 0.16% (80 mg/50 mL) HMW-HA (INSTYLAN) was instilled weekly into the bladder. The treatment consisted of 6 sessions (V1 to V6). Outcomes were assessed 1 week (V7) and 4 weeks (V8) after the last session and were compared with baseline (V0). The primary endpoint was bladder pain, evaluated by a Questionnaire with 5 closed-ended response options. Secondary endpoints included changes from baseline for hematuria, urinary frequency, and the effect of urgencies on Quality of Life (QoL). Adverse events (AEs) were graded according to the CTCAE 3.0 classification. RESULTS A total of 30 participants were enrolled. The Intent-to-Treat analysis showed a significant reduction in pelvic pain intensity (- 45.81%, p < 0.001), hematuria (- 26.87%, p = 0.008), total 24 h voids (- 23.92%, p < 0.001) and the effect of urgencies on QoL (- 33.92%, p < 0.001) at V7. The improvement for each outcome remained stable during the post-therapeutic period between V7 and V8. Bladder instillation therapy was well-tolerated: two treatment-related AEs (6.6%) were reported corresponding to two grade 1 hematuria. CONCLUSIONS Intravesical instillation of HMW-HA appears to be effective in the treatment of radiation-induced cystitis. Further comparative studies with longer follow-up are needed to confirm our preliminary results.
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Affiliation(s)
- Michael Baboudjian
- Department of Urology and Kidney Transplantation, La Conception Hospital, Aix-Marseille University, APHM, Marseille, France.
| | - Marc Fourmarier
- Department of Urology, CH Aix-Pertuis, Aix-en-Provence, France
| | | | - Arnaud Cherasse
- Department of Urology, Clinique du Val d'Ouest, Ecully, France
| | - Jean-Pierre Graziana
- Department of Urology, Clinique Mutualiste de la Porte de L'Orient, Lorient, France
| | | | | | - Sylvain Ducrocq
- Department of Urology, CH Notre Dame de la Miséricorde, Ajaccio, France
| | - Bastien Gondran-Tellier
- Department of Urology and Kidney Transplantation, La Conception Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Christian Saussine
- Department of Urology, NHC, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Vanneste BGL, Van Limbergen EJ, Marcelissen TA, van Roermund JGH, Lutgens LC, Arnoldussen CWKP, Lambin P, Oelke M. Development of a Management Algorithm for Acute and Chronic Radiation Urethritis and Cystitis. Urol Int 2021; 106:63-74. [PMID: 34130300 DOI: 10.1159/000515716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this review was to summarize the current literature on the assessment and treatment of radiation urethritis and cystitis (RUC) for the development of an evidenced-based management algorithm. MATERIAL AND METHODS The PubMed/MEDLINE database was searched by a multidisciplinary group of experts in January 2021. RESULTS In total, 48 publications were identified. Three different types of RUC can be observed in clinical practice: inflammation-predominant, bleeding-predominant, and the combination of inflammation- and bleeding-RUC. There is no consensus on the optimal treatment of RUC. Inflammation-predominant RUC should be treated symptomatically based on the existence of bothersome storage or voiding lower urinary tract symptom as well as on pain. When bleeding-predominant RUC has occurred, hydration and hyperbaric oxygen therapy (HOT) should be used first and, if HOT is not available, oral drugs instead (sodium pentosane polysulfate, aminocaproic acid, immunokine WF 10, conjugated estrogene, or pentoxifylline + vitamin E). If local bleeding persists, focal therapy of bleeding vessels with a laser or electrocoagulation is indicated. In case of generalized bleeding, intravesical installation should be initiated (formalin, aluminium salts, and hyaluronic acid/chondroitin). Vessel embolization is a less invasive treatment with potentially less complications and good clinical outcomes. Open- or robot-assisted surgery is indicated in patients with permanent, life-threatening bleeding, or fistulae. CONCLUSIONS Treatment of RUC, if not self-limiting, should be done according to the type of RUC and in a stepwise approach. Conservative/medical treatment (oral and topic agents) should primarily be used before invasive (transurethral) treatments.
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Affiliation(s)
- Ben G L Vanneste
- Department of Radiation Oncology (MAASTRO clinic), GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO clinic), GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tom A Marcelissen
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Joep G H van Roermund
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ludy C Lutgens
- Department of Radiation Oncology (MAASTRO clinic), GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Philippe Lambin
- The D-Lab, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Matthias Oelke
- Department of Urology, St. Antonius Hospital, Gronau, Germany
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Petca RC, Popescu RI, Toma C, Dumitrascu MC, Petca A, Sandru F, Chibelean CB. Chemical hemorrhagic cystitis: Diagnostic and therapeutic pitfalls (Review). Exp Ther Med 2021; 21:624. [PMID: 33936281 DOI: 10.3892/etm.2021.10056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/23/2021] [Indexed: 11/06/2022] Open
Abstract
Chemical cystitis (CC) is an inflammation of the bladder caused by various chemical agents ingested intentionally or accidentally. It is linked to chemotherapeutic agents such as cyclophosphamide, therapeutic agents for diverse diseases, and anesthetic agents consumed abusively for recreational effects such as ketamine, or can be linked to environmental and surrounding factors such as soaps, gels, spermicides, and dyes. CC is a pathology with an increasing incidence that is inadequately treated due to its infectious cystitis-like symptoms. The hemorrhagic form can have a rampant evolution. Treatment options of CC and its complications are under continuous research with no accepted standardized sequence. In many situations, the treatments are difficult to obtain, administer, and follow-up. In addition, the lack of experience of the physician may pose other obstacles in delivering treatment to the patient. In conclusion, CC is a disease with an increasing incidence, challenging to diagnose, which is frequently mistreated, and has multiple treatment modalities that still require standardization in administration and sequencing.
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Affiliation(s)
- Razvan-Cosmin Petca
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Urology, 'Prof. Dr. Th. Burghele' Clinical Hospital, 050659 Bucharest, Romania
| | - Razvan-Ionut Popescu
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Urology, 'Prof. Dr. Th. Burghele' Clinical Hospital, 050659 Bucharest, Romania
| | - Cristian Toma
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Urology, 'Prof. Dr. Th. Burghele' Clinical Hospital, 050659 Bucharest, Romania
| | - Mihai Cristian Dumitrascu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Obstetrics and Gynecology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Florica Sandru
- Department of Dermatology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Calin Bogdan Chibelean
- Department of Urology, 'George Emil Palade' University of Medicine, Pharmacy, Science and Technology of Targu-Mures, 540139 Targu-Mures, Romania.,Department of Urology, Mureș County Hospital, 540136 Targu-Mures, Romania
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14
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Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present. Int Neurourol J 2021; 25:119-127. [PMID: 33504132 PMCID: PMC8255820 DOI: 10.5213/inj.2040202.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.
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15
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Helissey C, Cavallero S, Brossard C, Dusaud M, Chargari C, François S. Chronic Inflammation and Radiation-Induced Cystitis: Molecular Background and Therapeutic Perspectives. Cells 2020; 10:E21. [PMID: 33374374 PMCID: PMC7823735 DOI: 10.3390/cells10010021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/10/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Carole Helissey
- Department of Radiation Biological Effects, French Armed Forces Biomedical Research Institute, 91220 Brétigny-sur-Orge, France; (C.H.); (S.C.); (C.C.)
- Clinical Unit Research, HIA Bégin, 94160 Saint-Mandé, France
| | - Sophie Cavallero
- Department of Radiation Biological Effects, French Armed Forces Biomedical Research Institute, 91220 Brétigny-sur-Orge, France; (C.H.); (S.C.); (C.C.)
| | - Clément Brossard
- Radiobiology of Medical Exposure Laboratory (LRMed), Institute for Radiological Protection and Nuclear Safety (IRSN), 92260 Fontenay-aux-Roses, France;
| | - Marie Dusaud
- Department of Urology, HIA Bégin, 94160 Saint-Mand, France;
| | - Cyrus Chargari
- Department of Radiation Biological Effects, French Armed Forces Biomedical Research Institute, 91220 Brétigny-sur-Orge, France; (C.H.); (S.C.); (C.C.)
- Gustave Roussy Comprehensive Cancer Center, Department of Radiation Oncology, 94805 Villejuif, France
- French Military Health Academy, Ecole du Val-de-Grâce (EVDG), 75005 Paris, France
| | - Sabine François
- Department of Radiation Biological Effects, French Armed Forces Biomedical Research Institute, 91220 Brétigny-sur-Orge, France; (C.H.); (S.C.); (C.C.)
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16
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Padayachee WPR, Sadhwani S, Doherty SW, Mukendi AM, Van den Berg E, Botha AR. Haemorrhagic cystitis due to cytomegalovirus in a patient with AIDS. AFRICAN JOURNAL OF UROLOGY 2020. [DOI: 10.1186/s12301-020-00039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cytomegalovirus-related infections are commonly seen in immunocompromised patients. However, haemorrhagic cystitis is an exceptionally rare associated manifestation. We present an unusual case of cytomegalovirus-related haemorrhagic cystitis in a patient with acquired immune deficiency syndrome (AIDS).
Case presentation
A 33-year-old HIV-positive female presented with acute gross haematuria and suprapubic pain. Cystoscopy revealed features suggestive of haemorrhagic cystitis with clots in the bladder and an ulcerative lesion on the left lateral wall which was biopsied. Histology demonstrated the presence of enlarged cells containing eosinophilic intranuclear and ill-defined amphophilic intracytoplasmic inclusions. Immunohistochemistry was positive for cytomegalovirus.
Conclusion
This case appears to be the first of its kind reported in South Africa highlighting the importance of considering cytomegalovirus as a potential infectious aetiology in AIDS patients with haematuria. Bladder irrigation with normal saline with or without clot evacuation combined with Ganciclovir are associated with good outcome.
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17
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Egan J, Vranic G, Ghasemian SR. Alum irrigation for the treatment of adenovirus induced hemorrhagic cystitis in a kidney transplant recipient. Urol Case Rep 2020; 30:101042. [PMID: 32055446 PMCID: PMC7005441 DOI: 10.1016/j.eucr.2019.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022] Open
Abstract
Adenovirus is a rare cause of hemorrhagic cystitis in the transplant population. We present a case of a forty-one-year-old man with end-stage renal disease who underwent living unrelated donor kidney transplant in 2016. In 2018 he presented with acute onset gross hematuria and dysuria, with serologic testing and immunohistochemical stains of biopsy specimens positive for adenovirus. He was treated with reduction in immunosuppression, cystoscopy with evacuation of clots, and alum bladder irrigation. His hematuria resolved almost immediately with no recurrence to date. This case demonstrates the efficacy and safety of alum irrigation in patients with adenovirus hemorrhagic cystitis.
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18
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Radiation Cystitis: a Contemporary Review. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00538-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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A contemporary review about the management of radiation-induced hemorrhagic cystitis. Curr Opin Support Palliat Care 2019; 12:344-350. [PMID: 30015689 DOI: 10.1097/spc.0000000000000375] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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20
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Goucher G, Saad F, Lukka H, Kapoor A. Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J 2019; 13:15-23. [PMID: 30721124 PMCID: PMC6363576 DOI: 10.5489/cuaj.5788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- George Goucher
- Department of Surgery (Urology) and Oncology, McMaster University, Hamilton, ON, Canada
| | - Fred Saad
- Department of GU Oncology, l’Université de Montréal, Montreal, QC, Canada
| | - Himu Lukka
- Department of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | - Anil Kapoor
- Department of Surgery (Urology) and Oncology, McMaster University, Hamilton, ON, Canada
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21
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Huang CP, Chen CC, Tsai YT, Wu CC, Shyr CR. Intravesical Administration of Xenogeneic Porcine Urothelial Cells Attenuates Cyclophosphamide-Induced Cystitis in Mice. Cell Transplant 2019; 28:296-305. [PMID: 30675801 PMCID: PMC6425110 DOI: 10.1177/0963689718822773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Chi-Ping Huang
- Departments of Medical Laboratory Science and Biotechnology and Urology, Sex Hormone Research Center, China Medical University and Hospital, Taichung
| | - Chi-Cheng Chen
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung
| | - Yi-Tung Tsai
- Departments of Medical Laboratory Science and Biotechnology and Urology, Sex Hormone Research Center, China Medical University and Hospital, Taichung
| | - Chun-Chie Wu
- Departments of Medical Laboratory Science and Biotechnology and Urology, Sex Hormone Research Center, China Medical University and Hospital, Taichung
| | - Chih-Rong Shyr
- Departments of Medical Laboratory Science and Biotechnology and Urology, Sex Hormone Research Center, China Medical University and Hospital, Taichung
- Chih-Rong Shyr, Sex Hormone Research Center, Departments of Medical Laboratory Science and Biotechnology, China Medical University and Hospital, No. 9, Hsiuh-Shih Rd, Taichung 404.
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22
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Doshi B, Sajjan V, Manjunathswamy BS. Managing a side effect: Cyclophosphamide-induced hemorrhagic cystitis. INDIAN JOURNAL OF DRUGS IN DERMATOLOGY 2019. [DOI: 10.4103/ijdd.ijdd_31_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Pascoe C, Duncan C, Lamb BW, Davis NF, Lynch TH, Murphy DG, Lawrentschuk N. Current management of radiation cystitis: a review and practical guide to clinical management. BJU Int 2018; 123:585-594. [PMID: 30113758 DOI: 10.1111/bju.14516] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Haemorrhage is a frequent complication of radiation cystitis leading to emergency presentations in patients with prior pelvic radiation therapy. Standard initial patient management strategies involve resuscitation, bladder washout with clot evacuation and continuous bladder irrigation. Beyond this, definitive surgical treatment is associated with significant morbidity and mortality. Alternative less invasive management options for non-emergent haemorrhagic cystitis include systemic medical therapies, hyperbaric oxygen (HBO), intravesical therapies and laser ablation. However, evidence to support and compare treatment for haemorrhagic radiation cystitis is limited. METHODS Herein, a literature search pertaining to the current management of haemorrhagic cystitis was conducted. RESULTS In total, 23 studies were included in this review with 2 studies reviewing systemic therapy, 7 studies evaluating HBO therapy, 10 studies investigating a variety of intravesical therapies and the remaining 4 were relating to ablative therapies. Across these studies, the patient groups were heterogenous with small numbers and variable follow up periods. CONCLUSION With evaluation of existing literature, this narrative review also provides a stepwise clinical algorithm to aid the urologist in treating patients presenting with complications associated with radiation cystitis.
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Affiliation(s)
- Claire Pascoe
- Department of Cancer Surgery, Peter MaCallum Cancer Centre, Melbourne, Vic., Australia.,Department of Urology, Austin Health Heidelberg, Heidelberg, Vic., Australia
| | - Catriona Duncan
- Department of Urology, Austin Health Heidelberg, Heidelberg, Vic., Australia.,North Eastern Urology, Heidelberg, Vic., Australia
| | - Benjamin W Lamb
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Niall F Davis
- Department of Urology, Austin Health Heidelberg, Heidelberg, Vic., Australia
| | - Thomas H Lynch
- Department of Urology, St James Hospital, Dublin 8, Ireland
| | - Declan G Murphy
- Department of Cancer Surgery, Peter MaCallum Cancer Centre, Melbourne, Vic., Australia
| | - Nathan Lawrentschuk
- Department of Cancer Surgery, Peter MaCallum Cancer Centre, Melbourne, Vic., Australia.,Department of Urology, Austin Health Heidelberg, Heidelberg, Vic., Australia
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