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: Hemorrhagic cystitis occurring after allogeneic transplant significantly affects quality of life and in some cases becomes intractable increasing the risk of death. To date, its therapy is not established. We used the hemostatic agent fibrin-glue to treat 35 patients with refractory post-transplant hemorrhagic cystitis. Of 322 adult patients undergoing an allogeneic transplant for hematological malignancy, 35 developed grade ≥2 hemorrhagic cystitis refractory to conventional therapy and were treated with fibrin-glue, diffusely sprayed on bleeding mucosa by an endoscopic applicator. The cumulative incidence of pain discontinuation and complete remission, defined as regression of all symptoms and absence of hematuria, was 100% at 7 days and 83±7% at 50 days from fibrin-glue application, respectively. The 6-month probability of overall survival for all 35 patients and for the 29 in complete remission was 49±8% and 59±9%, respectively. In the matched pair analysis, the 5-year probability of overall survival for the 35 patients with hemorrhagic cystitis and treated with fibrin-glue was not statistically different from that of the comparative cohort of 35 patients who did not develop hemorrhagic cystitis (32±9% vs 37±11%, p=ns). Fibrin-glue therapy is a feasible, effective, repeatable and affordable procedure for treating grade ≥ 2 hemorrhagic cystitis after allogeneic transplant.
    Biology of Blood and Marrow Transplantation 10/2014; 20(10). DOI:10.1016/j.bbmt.2014.06.018 · 3.35 Impact Factor
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    ABSTRACT: Purpose of review To better understand the mechanism of radiation-induced hemorrhagic cystitis and the advantages and disadvantages of available treatment options for bladder hemorrhage as well as preventive measures. Recent findings There have been several attempts recently to manage hemorrhagic cystitis with hyperbaric oxygen therapy, transurethral coagulation using Greenlight potassium-titanyl-phosphate laser and other different treatment modalities, but we still need more investigation on larger cohort studies. Summary Hemorrhagic cystitis is an uncommon urological problem. It is most often caused by radiation therapy and cyclophosphamide, but can be associated with other contributing factors. Technological advances in radiation therapy have resulted in greater treatment efficacy, with significant reduction in side-effects such as hemorrhagic cystitis. Higher dose radiation treatment, however, is more often associated with problematic hemorrhagic cystitis. Treatment of hemorrhagic cystitis is multifactorial and can range from simple bladder irrigation to cystectomy with urinary diversion.
    Current Opinion in Supportive and Palliative Care 07/2014; 8(3). DOI:10.1097/SPC.0000000000000073
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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.
    The Journal of Urology 06/2014; 192(6). DOI:10.1016/j.juro.2014.06.030 · 3.75 Impact Factor

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