Evaluation of the impact of the urinary symptoms on quality of life of patients with painful bladder syndrome/chronic pelvic pain and radiation cystitis: EURCIS study

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.

Validation of Polymorphisms Associated with the Risk of Radiation-Induced Oesophagitis in an Independent Cohort of Non-Small-Cell Lung Cancer Patients

Simple Summary

Genetic variants identified in association with radiation therapy side effects in non-small-cell lung cancer patients require an independent validation. Therefore, the aim of our study was to replicate, in an independent cohort, the analyses of previously published studies associating single-nucleotide polymorphisms with radiation-induced oesophagitis. Following the original models, 2 of the 18 variants associated with radiation-induced oesophagitis in non-small-cell lung cancer patients were confirmed. Furthermore, we meta-analysed our cohort together with those of the reference studies. Twelve variants located in genes of inflammation and DNA double-strand break repair pathways remained associated with oesophagitis. These variants could be included in models for clinical prediction of radiation-induced oesophagitis to evaluate their performance.

Abstract

Several studies have identified single-nucleotide polymorphisms (SNPs) associated with adverse effects in non-small-cell lung cancer (NSCLC) patients treated with radiation therapy. Here, using an independent cohort, we aimed to validate the reported associations. We selected 23 SNPs in 17 genes previously associated with radiation-induced oesophagitis for validation in a cohort of 178 Spanish NSCLC patients. Of them, 18 SNPs were finally analysed, following the methods described in the original published studies. Two SNPs replicated their association with radiation-induced oesophagitis (rs7165790 located in the BLM gene: odds ratio (OR) = 0.16, 95% CI = 0.04–0.65, p-value = 0.010; rs4772468 at FGF14: OR = 4.36, 95% CI = 1.15–16.46, p-value = 0.029). The SNP rs2868371 at HSPB1 was also validated but displayed an opposite effect to the formerly described (OR = 3.72; 95% CI = 1.49–9.25; p-value = 0.004). Additionally, we tested a meta-analytic approach including our results and the previous datasets reported in the referenced publications. Twelve SNPs (including the two previously validated) retained their statistically significant association with radiation-induced oesophagitis. This study strengthens the role of inflammation and DNA double-strand break repair pathways in the risk prediction of developing radiation-induced oesophagitis in NSCLC patients. The validated variants are good candidates to be evaluated in risk prediction models for patient stratification based on their radiation susceptibility.

Outcome of a 980-nm diode laser coagulation in women with radiation-induced hemorrhagic cystitis: a single-center retrospective study

The purpose of this study was to evaluate the efficacy of a 980-nm diode laser coagulation in women with radiation-induced hemorrhagic cystitis (RHC). We conducted a retrospective study of 21 RHC patients treated with a 980-nm diode laser between July 2014 and December 2017 at our institution. Data was collected with regard to age, sex, lower urinary tract symptoms, use of transfusions, a drop in hemoglobin levels, indication of radiotherapy, median time between radiation therapy and presentation, previous treatments, operative time, mean energy used, number of coagulated areas, catheterization time, discharge time after treatment, hospital stay, and surgical outcome. All 21 patients were women with a median age of 52 years (range 36-68 years). Eighteen patients complained of frequency and urgency, four patients had dysuria, and one patient developed urinary retention. Radiation therapy was primarily indicated in the treatment of cervical cancer in 18 patients (85.7%) and endometrial cancer in three patients (14.3%). Nine patients (42.8%) received blood transfusion before surgery and three patients (14.3%) needed blood transfusion after the procedure. The mean decrease in hemoglobin prior to the procedure was 4.08 ± 2.04 g/dL. The median length of time from completion of radiotherapy to the presentation of hematuria was 38 months (range 8-65 months). All patients had failed an adequate trial of conservative treatment which included adequate hydration, hemostatics, continuous bladder irrigation (CBI), and clot evacuation at the bedside. Eleven patients (52.4%) had previously been treated with endoscopic electrocoagulation; the mean number of procedures was 1.73 ± 0.78 (range 1-3 sessions). Six patients (28.6%) underwent HBO, and sodium hyaluronate solution irrigation was administered to 3 patients (14.3%). The mean number of HBO sessions was 26.3 ± 16.8 (range 8-50), and the mean number of sodium hyaluronate solution irrigation procedures was 4.33 ± 1.53 (range 3-6). All operations were successful. The mean operative time was 45.6 ± 12.3 min, the mean number of coagulated areas was 11.7 ± 4.4, the mean energy used was 2.74 ± 1.14 kJ, the mean catheterization time was 6.2 ± 0.9 days, the mean discharge time after treatment was 6.8 ± 1.2 days, and the average length of a hospital stay was 7.4 ± 1.3 days. In 16 patients (76.2%), hematuria was completely resolved after one session of diode laser coagulation. Four patients (19.0%) underwent multiple sessions of laser treatment due to recurrent gross hematuria (three patients required two sessions and one patient required three sessions). Only one patient (4.8%) who had persistent gross hematuria after diode laser treatment (two sessions) underwent a radical cystectomy, which resolved the hematuria. The median hematuria-free interval of patients who had multiple procedures was 9 months (range 1-13 months). In total, 21 patients underwent 27 sessions of diode laser coagulation, and the median hematuria-free interval was 16 months (range 1-45 months) with a median follow-up of 25 months (range 7-48 months). Our study shows promising results for the management of patients with RHC; however, further evaluation with a larger cohort is required to confirm the efficacy of this treatment.

Endoscopic Intravesical Fibrin Glue Application in the Treatment of Refractory Hemorrhagic Radiation Cystitis: A Single Cohort Pilot Study

OBJECTIVE

To evaluate the clinical value of endoscopic fibrin glue (FG) application therapy in treating hemorrhagic radiation cystitis (HRC).

PATIENTS AND METHODS

This is a single-cohort, prospective pilot study. We collected data from patients with HRC who were treated at our urology unit from May 2014 to December 2016. Patients with grade ≥2 HRC for whom conventional therapy and transurethral endoscopic electrocoagulation had failed were treated with endoscopic intravesical FG. The mean follow-up was 26.2 ± 9.78 months. Our analysis included data on patient demographics, pelvic malignancies, radiotherapy regimens, total dose of radiation received, time of onset and severity of hematuria, and previous intravesical management. Following FG intervention, patients' clinical status was defined as: (1) clinical response; absence of dysuria, urgency, and frequency; discontinuation of analgesic medication; and Foley catheter removal, but with ongoing hematuria grade <2; (2) complete response, clinical response, and no further hematuria; or (3) no response, no clinical response, and sustained hematuria.

RESULTS

A total of 20 patients (12 women and 8 men; mean age, 69 ± 7.5 years) were treated with 12 mL FG intravesically, using endoscopic application. Of the 20 patients, 16 (80%) had a complete response and 4 (20%) had a clinical response. In the case of four patients (20%), treatment was carried out twice. Mean hospital stay was 6 ± 2.5 days. The intervention showed good tolerability in all patients. No major adverse events were reported. Bladder spasms were the only minor adverse events reported in six patients (30%).

CONCLUSION

Application of FG is an effective, practical, affordable, and repeatable procedure for the treatment of grade ≥2 HRC.

Variations in bladder pain syndrome/interstitial cystitis (IC) definitions, pathogenesis, diagnostics and treatment: a systematic review and evaluation of national and international guidelines

INTRODUCTION AND HYPOTHESIS

Interstitial cystitis (IC) and bladder pain syndrome (BPS) are challenging and encompassing hypersensitivity disorders of the lower urinary tract. A variety of national and international guidelines have been published including guidance on nomenclature, definitions, etiopathology, diagnostics and treatment. A lack of universally established clinical guidance is apparent. The aim of this review is to evaluate key guidelines on this area of practice, identify variations, compare their recommendations and grade them using AGREE II.

METHODS

Literature searches were performed using the PUBMED and CINAHL database from January 1, 1983, to December 1, 2018, referring to the search strategy of AUA. Ten national and international guidelines were included into the analysis. We assessed the guidelines with the updated AGREE II.

RESULTS

Symptoms congruent in all guidelines are: pain, pressure, discomfort and frequency, urgency and nocturia. Urinalysis is a prerequisite for diagnostics, cystoscopy for most and urodynamics not part of the routine assessment. Treatment options are recommended stepwise. The highest level of evidence and consensus was identified for oral therapies. Nine guidelines had an overall quality score ≥ 50% and three scored ≥ 70% (AUA, GG, RCOG).

CONCLUSIONS

The guidelines are congruent in symptom reporting, quite congruent in diagnostics and vary to a high degree on treatment recommendations. The complexity of BPS and emerging evidence indicate the need for regular updating of the guidelines and a wider consensus.

Bladder pain syndrome: Prevalence and routine clinical practice in women attending functional urology and urodynamics units in Spain

INTRODUCTION AND OBJECTIVES

Bladder pain syndrome (BPS) is classified as a rare chronic debilitating disease and its diagnosis presents a challenge because its symptoms overlap with those associated with overactive bladder syndrome. The aim of the routine study was to estimate the prevalence of BPS and discover to study the profile of symptoms and clinical practice for patients attending functional urology and urodynamics units.

MATERIAL AND METHODS

An epidemiological study in which 37 functional urology and urodynamics units in Spain participated. The prevalence was studied in both sexes. Clinical practice was evaluated for 319 women with BPS (new diagnosis or under review). Clinical and sociodemographic data were collected retrospectively. The results were studied of urine tests, cystoscopy, biopsy, physical examination, bladder diary, and those of the four available questionnaires: Patient Perception of Bladder Condition; Bladder Pain/Interstitial Cystitis Symptom Score; EuroQoL-5 Dimensions-5L and Patient Global Impression of Severity.

RESULTS

Five point four percent (503) of the patients who attended these units (9,312) had a diagnosis of BPS (90% [453] females). The tests that were performed most according to the clinical history and anamnesis were: urine test, bladder ultrasound and cystoscopy. The most common symptoms/comorbidities were: pain in the bladder region, increased urinary frequency, nocturia, anxiety and depression. Diagnostic assessment determined pain on hydrodistension (86.9%), positive biopsy (59.2%), myofascial pelvic pain (28.4%), urological phenotype (97.8%), and increased urinary frequency (88.7%). The questionnaires reflected how much the quality of life of these patients was affected.

CONCLUSIONS

The prevalence of BPS in functional urology and urodynamics units in Spain is low. No homogeneity was observed in terms of diagnosis between the different participating centres. Therefore, a common methodology is required for the management of patients with BPS in these units, with tools specific to this disorder.

Psychosocial co-morbidities in Interstitial Cystitis/Bladder Pain syndrome (IC/BPS): A systematic review

AIMS

Psychosocial factors amplify symptoms of Interstitial Cystitis (IC/BPS). While psychosocial self-management is efficacious in other pain conditions, its impact on an IC/BPS population has rarely been studied. The objective of this review is to learn the prevalence and impact of psychosocial factors on IC/BPS, assess baseline psychosocial characteristics, and offer recommendations for assessment and treatment.

METHOD

Following PRISMA guidelines, primary information sources were PubMed including MEDLINE, Embase, CINAHL, and GoogleScholar. Inclusion criteria included: (i) a clearly defined cohort with IC/BPS or with Chronic Pelvic Pain Syndrome provided the IC/BPS cohort was delineated with quantitative results from the main cohort; (ii) all genders and regions; (iii) studies written in English from 1995 to April 14, 2017; (iv) quantitative report of psychosocial factors as outcome measures or at minimum as baseline characteristics.

RESULTS

Thirty-four of an initial 642 articles were reviewed. Quantitative analyses demonstrate the magnitude of psychosocial difficulties in IC/BPS, which are worse than average on all measures, and fall into areas of clinical concern for 7 out of 10 measures. Meta-analyses shows mean Mental Component Score of the Short-Form 12 Health Survey (MCS) of 40.80 (SD 6.25, N = 2912), where <36 is consistent with severe psychological impairment. Averaged across studies, the population scored in the range seen in clinical depression (CES-D 19.89, SD 13.12, N = 564) and generalized anxiety disorder (HADS-A 8.15, SD 4.85, N = 465).

CONCLUSION

The psychological impact of IC/BPS is pervasive and severe. Existing evidence of treatment is lacking and suggests self-management intervention may be helpful.

Assessment of the quality of life and sexual functions of patients followed-up for non-muscle invasive bladder cancer: preliminary results of the prospective-descriptive study

OBJECTIVE

The aim of this study is to evaluate sexual functions and quality life of patients who are followed-up for non-muscle invasive bladder cancer (NMIBC).

MATERIAL AND METHODS

Between March 2015-June 2016, 50 patients underwent cystoscopy for NMIBC. At the end of the 1^st year follow-up patients were assessed for sexual functions using 5-item version of the International Sexual Function Index (IIEF-5) for male and the Female Sexual Function Index(FSFI) for female; for quality of life (QoL) by the European Organisation for Research and Treatment of Cancer-Non-Muscle Invasiv Bladder Cancer Quality of Life Questionnaire (EORTC QLQ-NMIBC24) and for emotional status by Beck depression inventory.

RESULTS

There were 44 male and 6 female patients with the mean age of 57.6±11.5 years. Twenty patients received intravesical treatment after transurethral resection of bladder tumour. The mean Beck (10.7±9.5) IIEF-5 (15.6±5.9), FSFI (19.2±10.9), and the EORTC-QLQ NMBIC 24 (38.2±7.7) scores of the patients were determined as indicated. Among the patients, 42 (84%) of them were not feeling bad about their bladder tumors and 37 (74%) were not worrying about their daily lives. Moreover, 12 (24%) patients were not interested with sexuality, while 27 (54%) of them did not feel comfortable about sexual sincerity. Interestingly, 27 patients receiving intravesical treatment were concerned that the treatment they received for prevention of recurrence and progression of bladder tumor infect their partners during sexual intercourse.

CONCLUSION

NMIBC affects patients' sexual functions and QoL negatively. Therefore during the follow-up of these patients, it is important to inform these patients accurately about their treatments to be applied and predicted complications in the follow up period.

Study of the apoptotic effect of urine as a diagnostic biomarker in patients with interstitial cystitis

INTRODUCTION

The main objective of the study was to assess the apoptotic effect of urine from patients with interstitial cystitis (IC) in cell cultures and to study its value as a diagnostic biomarker for IC.

MATERIAL AND METHODS

A prospective study was conducted between January 2010 and January 2015 and included 57 patients diagnosed with IC and 50 healthy patients from the Hospital Clinic of Barcelona and the La Paz University Hospital. The urine of these patients was exposed to cell cultures, and its ability to induce apoptosis in the cultures was analysed. Using flow cytometry, we then measured the degree of apoptosis, quantified by the percentage of cells of the cell cycle in phase sub G0.

RESULTS

The cell cultures exposed to the urine of patients with IC had a sub G1 peak and a G2 phase, which was significantly greater than that of the control group, and a significantly lower percentage in the S phase than the control group. The mean apoptosis values in the urine cultures from patients with IC were significantly higher than those of the control group. Using a value >10% of the apoptosis test as a positive result, we observed a specificity of 96% and a positive predictive value of 92%.

CONCLUSIONS

The urine of patients with IC exerts an apoptotic effect on tumour cell cultures that is significantly greater than that exerted by the urine of healthy control patients. A≥10% cutoff for the apoptosis test presented very low sensitivity (40%) but had a very high specificity (96%), thereby able to confirm the diagnosis of IC when positive.

Post-Irradiation Bladder Syndrome After Radiotherapy of Malignant Neoplasm of Small Pelvis Organs: An Observational, Non-Interventional Clinical Study Assessing VESIcare®/Solifenacin Treatment Results

Background

Radiotherapy is explicitly indicated as one of the excluding factors in diagnosing overactive bladder syndrome (OAB). Nevertheless, symptoms of OAB such as urgent episodes, incontinence, pollakiuria, and nocturia, which are consequences of irradiation, led us to test the effectiveness of VESIcare^®/Solifenacin in patients demonstrating these symptoms after radiation therapy of small pelvis organs due to malignant neoplasm.

Material/Methods

We conducted an observatory clinical study including 300 consecutive patients with symptoms of post-irradiation bladder; 271 of those patients completed the study. The observation time was 6 months and consisted of 3 consecutive visits taking place at 12-week intervals. We used VESIcare® at a dose of 5 mg a day. Every sixth patient was examined urodynamically at the beginning and at the end of the observation period, with an inflow speed of 50 ml/s.

Results

We noticed improvement and decline in the average number of episodes a day in the following parameters: number of micturitions a day (−36%, P<0.01), nocturia (−50%, P<0.01), urgent episodes (−41%, P<0.03), and episodes of incontinence (−43%, P<0.01). The patients’ quality of life improved. The average maximal cystometric volume increased by 34 ml (21%, p<0.01), average bladder volume of “first desire” increased by 42 ml (49%, P<0.01), and average detrusor muscle pressure at maximal cystometric volume diminished by 9 cmH₂O (−36%, P<0.03).

Conclusions

The substance is well-tolerated. Solifenacin administered long-term to patients with symptoms of OAB after radiotherapy of a malignant neoplasm of the small pelvis organs has a daily impact in decreasing number of urgent episodes, incontinence, pollakiuria, and nocturia.

Quality-of-life survey for patients diagnosed with nonmuscle-invasive bladder cancer

OBJECTIVE

To determine the reliability and validity of a quality-of-life survey for patients with nonmuscle-invasive bladder cancer.

MATERIAL AND METHODS

A total of 180 patients were included in the study. We developed a survey with 21 questions grouped into 5 areas. The patients filled in this survey and the Functional Assessment of Cancer Therapy - Bladder Cancer (FACT-BL) survey. To assess reliability, we calculated Cronbach's alpha coefficient and the kappa index. To determine criterion validity, we studied the association between the scores obtained from our survey and those from the FACT-BL survey using the Pearson correlation coefficient. To determine the construct validity (factorial and discriminatory), we performed a factor analysis, comparing it with Student's t-test for the scores obtained according to the tumour characteristics of reduced quality of life (e.g., malignancies located at the trigone of the bladder).

RESULTS

Cronbach's alpha reliability coefficient was .83, and the kappa index varied between .7 and 1. For the association study between the new survey and the FACT-BL survey, we measured an r=.82 for the overall score and between r=.68 (disease) and r=.97 (sex life) in the various measures. In the factor analysis, we measured a Kaiser-Meyer-Olkin index of .77 and performed the Barlett test (P<.001). The comparison between the scores, in the presence or absence of certain tumour characteristics, has shown a reduced quality of life when those characteristics are present, which was statistically significant (P<.05) in the majority of cases.

CONCLUSION

Our survey to measure the quality of life of patients with nonmuscle-invasive bladder cancer is reliable and valid.

A Narrative Review on the Pathophysiology and Management for Radiation Cystitis

Radiation cystitis is a recognised complication of pelvic radiotherapy. Incidence of radiation cystitis ranges from 23 to 80% and the incidence of severe haematuria ranges from 5 to 8%. High quality data on management strategies for radiation cystitis is sparse. Treatment modalities are subclassified into systemic therapies, intravesical therapies, and hyperbaric oxygen and interventional procedures. Short-term cure rates range from 76 to 95% for hyperbaric oxygen therapy and interventional procedures. Adverse effects of these treatment strategies are acceptable. Ultimately, most patients require multimodal treatment for curative purposes. Large randomised trials exploring emergent management strategies are required in order to strengthen evidence-based treatment strategies. Urologists encounter radiation cystitis commonly and should be familiar with diagnostic modalities and treatment strategies.