1
|
Bologna E, Licari LC, Franco A, Ditonno F, Manfredi C, De Nunzio C, Antonelli A, De Sio M, Coogan C, Vourganti S, Leonardo C, Simone G, Autorino R. Incidence and Management of Radiation Cystitis After Pelvic Radiotherapy for Prostate Cancer: Analysis from a National Database. Urology 2024:S0090-4295(24)00308-X. [PMID: 38692496 DOI: 10.1016/j.urology.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES To determine the incidence of radiation cystitis on Prostate Cancer (PCa) patients undergoing pelvic radiotherapy (RT), evaluating the most used management strategies, and identifying potential risk factors associated with the development of this condition. METHODS A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing patient records compiled between 2011 and 2022. International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population and outcomes. We evaluated patients who underwent RT for PCa and subsequently developed radiation cystitis. Primary objective was to determine the overall incidence of radiation cystitis. Furthermore, we investigated its associated risk factors and management. RESULTS A total of 274,865 PCa patients underwent RT during the study period. Of these, 48,713 (17.7%) experienced hematuria following RT, while 7,721 (2.8%) were diagnosed with radiation cystitis. After the diagnosis, 2,307 patients (29.9%) received diagnostic or therapeutic endoscopic interventions. Only 59 patients (0.76%) underwent endovascular embolization, while 151 patients (1.95%) required cystectomy. Hyperbaric oxygen therapy, administered to 1,287 patients (16.67%), was the only treatment that displayed a significant upward trend. Multivariate logistic regression identified obesity (OR 1.29; 95% C.I. 1.23 - 1.35), smoking (OR 1.27; 95% C.I. 1.22 - 1.33), and diabetes (OR 1.32; 95% C.I. 1.26 - 1.39), as significant risk factors for radiation cystitis (all p-values < 0.001). CONCLUSIONS Radiation cystitis represents a rare complication after pelvic RT with significant clinical impact. Its incidence has remained stable throughout the study period. The identified risk factors corroborate the pathophysiology of radiation cystitis. Hyperbaric oxygen therapy was the only treatment to show an upward trend during the study period.
Collapse
Affiliation(s)
- Eugenio Bologna
- Department of Urology, Rush University, Chicago, IL, USA; Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Leslie Claire Licari
- Department of Urology, Rush University, Chicago, IL, USA; Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Antonio Franco
- Department of Urology, Rush University, Chicago, IL, USA; Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University, Chicago, IL, USA; Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, University of Verona, Verona, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University, Chicago, IL, USA; Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Alessandro Antonelli
- Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, University of Verona, Verona, Italy
| | - Marco De Sio
- Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | | | - Costantino Leonardo
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | |
Collapse
|
2
|
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.
Collapse
|
3
|
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.
Collapse
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
| | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Pereira D, Ferreira C, Catarino R, Correia T, Cardoso A, Reis F, Cerqueira M, Prisco R, Camacho O. Hyperbaric oxygen for radiation-induced cystitis: A long-term follow-up. Actas Urol Esp 2020; 44:561-567. [PMID: 32736899 DOI: 10.1016/j.acuro.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES Bladder complications may be seen in up to 12% of patients treated with pelvic irradiation. Hyperbaric oxygen therapy (HBOT) is an option for the management of radiation-induced hemorrhagic cystitis (RIHC). The aim of this study was to evaluate the efficacy of HBOT in radiation cystitis and to identify the predictive factors for a successful outcome. MATERIAL AND METHODS We retrospectively reviewed 105 patients diagnosed with RIHC which were treated with HBOT between 2007 and 2016 in our institution. Patients received 100% oxygen in a multiplace hyperbaric chamber at 2.4atm for 80minutes. All patients fulfilled a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period. RESULTS After a median of 40 HBOT sessions, there was success rate of 92,4% in the control of hematuria. During our follow-up period (median of 63 months) 24,7% patients presented with recurrence of hematuria. The mean score of the questionnaire-assessed variables: dysuria, urinary frequency and hematuria, was significantly lower after the follow-up period (P<.05). Our data shows that the sooner HBOT is delivered after the first episode of hematuria, better response rates are achieved and lower recurrences concerning hematuria were registered (P<.05). No serious complications were observed. CONCLUSIONS Our results support the safety and long-term benefits of HBOT on RIHC and other distressful bladder symptoms, which represents an expected improvement of quality of life in our patients.
Collapse
|
6
|
Radiation-induced cystitis and hyperbaric oxygen therapy. Lancet Oncol 2019; 20:e660. [DOI: 10.1016/s1470-2045(19)30683-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
|
7
|
Oscarsson N, Müller B, Rosén A, Lodding P, Mölne J, Giglio D, Hjelle KM, Vaagbø G, Hyldegaard O, Vangedal M, Salling L, Kjellberg A, Lind F, Ettala O, Arola O, Seeman-Lodding H. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2–3 trial. Lancet Oncol 2019; 20:1602-1614. [DOI: 10.1016/s1470-2045(19)30494-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 12/31/2022]
|
8
|
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]
|
9
|
Villeirs L, Tailly T, Ost P, Waterloos M, Decaestecker K, Fonteyne V, Van Praet C, Lumen N. Hyperbaric oxygen therapy for radiation cystitis after pelvic radiotherapy: Systematic review of the recent literature. Int J Urol 2019; 27:98-107. [PMID: 31617263 DOI: 10.1111/iju.14130] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/17/2019] [Indexed: 11/27/2022]
Abstract
The present study assessed the efficacy of hyperbaric oxygen therapy in reducing symptoms of radiation cystitis, a specific type of iatrogenic injury to the bladder, by systematic review of recent literature. The MEDLINE, Embase and Web of Science databases were searched using combinations of the terms "radiation," "cystitis" and "hyperbaric oxygen" to identify articles evaluating patients with radiation cystitis, treated with hyperbaric oxygen therapy. Only recent (≤10 years) original studies were included. Data were extracted and pooled in order to calculate descriptive weighted averages. Articles were evaluated on their level of evidence. A total of 20 papers were obtained, resulting in a cohort of 815 patients who were treated with hyperbaric oxygen therapy for radiation cystitis. Overall and complete response rates varied from 64.8% to 100% and 20% to 100%, respectively. The weighted average overall and complete response rates were 87.3% and 65.3%, respectively. Adverse events were observed in 9.6% of the patients, but permanent side-effects were rare. The most prominent limitations were high cost and low availability. Hyperbaric oxygen therapy is effective in the treatment of radiation-induced cystitis, with minimal adverse events, but low availability and high cost. At present, evidence is low; therefore, more prospective studies are required.
Collapse
Affiliation(s)
- Lauren Villeirs
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Thomas Tailly
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Piet Ost
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Marjan Waterloos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium.,Department of Urology, General Hospital Maria Middelares, Ghent, Belgium
| | - Karel Decaestecker
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Valerie Fonteyne
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Charles Van Praet
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Nicolaas Lumen
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
10
|
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.
Collapse
|
11
|
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
| |
Collapse
|
12
|
Scoping Review and Meta-analysis of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis. Curr Urol Rep 2018; 19:38. [PMID: 29654564 DOI: 10.1007/s11934-018-0790-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW To critically review and summarize existing literature assessing the effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of radiation-induced urologic injury. RECENT FINDINGS Though 5 of the included 13 studies were published in the last 2-3 years, the only randomized controlled study was performed in 2012. Recent studies have confirmed the safety and efficacy of HBOT as well as identified risk factors for success vs. failure of HBOT for hemorrhagic radiation cystitis (HRC). Of the 602 patients that received HBOT for HRC, 84% had a partial or complete resolution. In the 7 studies that utilized RTOG/EORTC, 75% of patients saw an improvement in hematuria of at least one grade (out of possible 5 total). Of the 499 patients with documented follow-up, 14% experienced recurrence, with a median time to recurrence of 10 months (6 to 16.5 months).
Collapse
|