Radiation cystitis is an uncontrollable and unpreventable chronic alteration of the bladder due to any form of radiation therapy. This may occur at any point during follow-up (immediate to 20 years) and is progressive destruction of the bladder, ureter, and urethra. The pathophysiology includes an unpredictable evolution from remission, tamponade, or loss of urinary function.
The true incidence and prevalence of radiation cystitis are unknown. Dr. Colombel notes that at his center in Lyon, they follow 227 patients post-radiation therapy for radiation cystitis, of which 191 had primary prostate cancer, 21 cervical cancer, and 15 bladder cancer patients.
The grading of genitourinary toxicity is as follows:
- Grade 0: No change
- Grade I: Frequency or nocturia; does not require medication
- Grade II: frequency or nocturia (>1 h), dysuria, urgency, bladder spasm; requires treatment
- Grade III: frequency with urgency, nocturia (<1 hr), bladder spasm, gross hematuria; requires narcotics or endoscopic procedure
- Grade IV: hematuria requiring transfusion, bladder obstruction, ulceration, necrosis; often requires a loss of bladder function
- (i) Acute phase (several weeks): loss of the GAG layer, loss of urothelial cells, inflammation, edema, dilated blood vessels, urinary leakage, stromal cell atypia, and pseudocarcinomatous epithelial hyperplasia
- (ii) Latent phase (months to years): endarteritis, urothelial proliferation, and “leaky” urothelium (?)
- (iii) Late phase (chronic): increased collagen deposition, fibroblast infiltration, decreased smooth muscle cells, endarteritis, edema, hemorrhage, and inflammation
There are several intravesical therapies that may be tried with variable efficacy. These include alum instillations and amino caproic acid; Dr. Colombel strongly warns against formaldehyde instillation, as this wrought with complications and has a non-insignificant mortality rate. Hyperbaric oxygen has been used with decent success and usually works more efficaciously when utilized <6 months after radiation therapy. Hyperselective embolization is an option for refractory cases with moderate success, typically with a resolution of symptoms ~6 months after treatment. Cystectomy is typically a last effort after utilizing the above less invasive modalities. In a retrospective institutional review over more than a decade, 21 cases were identified: the Clavien IIIB-V complication rate for cystectomy in these cases was 42% and the mortality rate was 16%1. As such, cystectomy should only be used as a last resort.
Dr. Colombel concluded with the following algorithm for assessing and treating hematuria after radiation therapy:
Presented by: Marc Colombel, MD, Ph.D., Groupement Hospitalier Edouard Herriot, Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic
References:
1. Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for refractory hemorrhagic cystitis: Contemporary etiology, presentation, and outcomes. J Urol 2014 Dec;192(6):1687-1692.
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