Article

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

University College Hospital, London, UK.
BJU International (Impact Factor: 3.13). 06/2013; 112(7). DOI: 10.1111/bju.12291
Source: PubMed

ABSTRACT Haemorrhagic cystitis (HC) can be either acute or chronic, and be caused by chemotherapeutic drugs, radiation therapy, or exposure to chemicals, such as dyes or insecticides [1]. In transplantation settings, HC is typically associated with haematopoietic stem cell transplant (HSCT), but can also occur, albeit rarely, in solid organ recipients [2]. It is thought that a defect in the glycosaminoglycan (GAG) layer, which coats the uroepithelium and provides the initial barrier for physiologic protection, may be the first step in its development [3]. Once injured or defective, the GAG layer loses its barrier properties, becomes permeable, and allows the inflammatory and hypersensitisation cycle to thrive [3].

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    ABSTRACT: Purpose: We evaluate the clinical presentation, management and outcomes of patients undergoing cystectomy for refractory hemorrhagic cystitis. Materials and Methods: We identified 21 patients with refractory hematuria treated with cystectomy at our institution between 2000 and 2012. Clot evacuation, bladder fulguration and bladder irrigation had failed in all patients before cystectomy. In addition, 45% of patients had received prior intravesical therapy (aminocaproic acid, alum or formalin), hyperbaric oxygen therapy (25%), nephrostomy tube placement for attempted urinary diversion (15%) and/or selective bladder angioembolization (5%). Results: Median patient age at surgery was 77 years (IQR 72, 80) and 81% (17 of 21) of patients were male. The most common etiology for hemorrhagic cystitis was prior radiation therapy for prostate cancer (17, 81%). Median time from receipt of radiation to cystectomy in these patients was 91 months (IQR 73, 125). Median ASA (R) (American Society of Anesthesiologists) score at cystectomy was 3 and median preoperative hemoglobin was 10.2 gm/dl. Median length of stay after cystectomy was 10 days (IQR 7, 19). Severe (Clavien grade III to V) complications were noted in 42% of patients (8 of 19) and the 90-day mortality rate in this cohort was 16% (3 of 19). With a median postoperative followup of 13 months (IQR 4, 21), the 1 and 3-year overall survival was 84% and 52%, respectively. Conclusions: Cystectomy for hemorrhagic cystitis is associated with a high risk of perioperative complications and mortality, consistent with the baseline clinical status of this patient cohort and, as such, should remain a last resort to control bleeding after failure of conservative measures.
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