Radiation cystitis

Emergency department visits for radiation cystitis among patients with a prostate cancer history

OBJECTIVES

To elucidate the national burden of emergency department (ED) visits for radiation cystitis (RC), a known complication of radiation therapy (RT) to the pelvic area, among patients with a prostate cancer history, and identify those who are at increased risk of requiring invasive measures.

PATIENTS AND METHODS

This study queried the Nationwide Emergency Department Sample for all ED visits from January 2006 to December 2015 with a primary diagnosis of RC and secondary diagnosis of prostate cancer. ED visits were characterised by demographic factors, socioeconomic factors, and hospital characteristics. Weighted frequencies were used to create national estimates for all data analysis.

RESULTS

A weighted total of 17 382 ED visits occurred for RC among patients with a prostate cancer history, of which 9655 (55.5%) were treated with an invasive procedure. Notable factors associated with undergoing an invasive procedure included having a prior prostatectomy (odds ratio [OR] 5.48, 95% confidence interval [CI] 2.62-11.46), urinary retention (OR 1.35, 95% CI 1.12-1.64), haematuria (OR 1.20, 95% CI 1.01-1.42), and undergoing a blood transfusion (OR 2.12, 95% CI 1.72-2.62). ED visits that were associated with invasive procedures had a higher median total charge ($34 707.53 vs $15 632.53) and an increased median length of stay (5 vs 3 days) compared to visits without an invasive procedure.

CONCLUSIONS

Among ED visits for RC in prostate cancer, approximately one half required an invasive procedure for treatment. While RT remains an effective modality for patients with prostate cancer, providers should be mindful of RC as a potential complication.

Factors affecting urinary frequency after low-dose-rate brachytherapy for prostate cancer

OBJECTIVES

Lower urinary tract symptoms are transiently exacerbated by low-dose-rate brachytherapy (LDR-BT) for prostate cancer and recover to pretreatment levels 1 year thereafter. Generally, these symptoms are influenced by temperature. We aimed to search for factors affecting the lower urinary tract symptoms after seed implant including seasons.

METHODS

We retrospectively enrolled 812 patients who underwent LDR-BT at Nara Medical University Hospital from January 2010 to December 2018 and for whom the International Prostate Symptom Score, Overactive Bladder Symptom Score, and frequency volume charts were available. We investigated the relationships between lower urinary tract symptoms, 24-hours urinary frequency, 24-hours urinary volume before and after seed implant, radiation dose, and season of seed implant.

RESULTS

The mean age was 69.5 years. The mean prostate volume was 24.2 mL. The International Prostate Symptom Score, Overactive Bladder Symptom Score, and 24-hours urinary frequency increased until 3 months and gradually decreased over 6 months after seed implant. Multiple linear regression analysis revealed that 24-hours urinary frequency at 3 months after seed implant was significantly influenced by external beam radiotherapy, larger prostate volume before implant, higher 24-hours urinary frequency at baseline, larger 24-hours urinary volume at 3 months after implant, and performance of implant in summer.

CONCLUSIONS

Lower urinary tract symptoms worsened 3 months after seed implant of LDR-BT regardless of the season of implant. The urinary frequency 3 months after seed implant was slightly lower when seed implant was performed in the summer.

Chronic Inflammation and Radiation-Induced Cystitis: Molecular Background and Therapeutic Perspectives

Radiation cystitis is a potential complication following the therapeutic irradiation of pelvic cancers. Its clinical management remains unclear, and few preclinical data are available on its underlying pathophysiology. The therapeutic strategy is difficult to establish because few prospective and randomized trials are available. In this review, we report on the clinical presentation and pathophysiology of radiation cystitis. Then we discuss potential therapeutic approaches, with a focus on the immunopathological processes underlying the onset of radiation cystitis, including the fibrotic process. Potential therapeutic avenues for therapeutic modulation will be highlighted, with a focus on the interaction between mesenchymal stromal cells and macrophages for the prevention and treatment of radiation cystitis.

De novo OAB After ATOMS: An Underestimated Problem or a Rare Side Effect?

Background: The urinary incontinence system ATOMS (A.M.I., Austria) generates suburethral compression through its sphincter cushion. To what extent the ATOMS may lead to overactive bladder (OAB) symptoms or which risk factors for these symptoms exist remain unknown to date. We report on our multicentre evaluation on the prevalence, status, and therapy of OAB after ATOMS.

Methods: Between 10/09 and 01/17, a total of 361 patients received an ATOMS device in Vienna and Halle. A prerequisite for surgery was persistent male stress urinary incontinence lasting at least 6 months after the primary intervention, as well as the failure of conservative treatment. Patients with a preoperative untreated anastomotic stricture or detrusor overactivity were excluded. In addition to continence and voiding parameters, patient's age, BMI, comorbidities, and pre-treatment strategies of the underlying disease and urinary incontinence were examined. If de novo OAB was present, urodynamics were used for further clarification. Statistical analysis was performed with GraphPad Prism 7® (GraphPad Software, Inc., La Jolla, USA), p < 0.05 considered significant.

Results: OAB presented 18 patients (4.9%). Regarding the degree of urinary incontinence as well as uroflowmetry, residual volume and comorbidities, patients with an OAB showed no differences compared to patients without an OAB (p < 0.05). Only previous radiotherapy or urinary incontinence surgery and urethral stricture interventions resulted in statistically significant differences based on the bivariate analysis (p = 0.030, p = 0.006, p = 0.007). The consecutive postoperative urodynamics revealed a sensory OAB in 17 patients and a low-compliance bladder in a patient with newly diagnosed insulin-dependent type II diabetes mellitus. OAB was treated with a standard dose of antimuscarinic drugs and for the low-compliance bladder with botulinum toxin type A.

Conclusion: OAB symptoms can occur after ATOMS implantation, but are rare and have no clear correlation to the incontinence device but rather are due to urinary incontinence-related underlying diseases and previous treatments.

Iatrogenic Disease of the Genitourinary Tract

Iatrogenic disease is defined as illness caused by diagnostic procedures or treatment given by health care professionals. More recently described treatment complications involving the genitourinary tract include newly recognized variants of renal carcinoma in the setting of dialysis/end-stage renal disease, treatment effect in genitourinary carcinomas, and medical renal disease caused by drug therapies, including immunotherapy. The objective of this review is to cover iatrogenic inflammatory diseases, pseudotumors and tumors of the kidney, bladder, prostate, testis and paratestis of most interest to surgical pathologists. For this reason, disease caused by the following will not be covered: iatrogenic glomerulonephritis, self-inflicted injury including the introduction of foreign bodies, surgical error, drugs of abuse and herbal medications, and iatrogenic disease in the transplant setting including ischemia/reperfusion injury. Emphasis is placed upon commonly encountered diseases in order to ensure that the review is of utility to practicing pathologists. The clinical context, pathophysiology and histopathology of each disease entity are covered.

[Medical prevention and treatment of radiation-induced urological and nephrological complications]

Abdominal and pelvic irradiations play a major place in the management of patients with cancer and present a risk of acute and late side effects. Radiation-induced lesions can affect kidney or urological structures. These side effects can have an impact in the quality of life of patients. The aim of this article is to describe the physiopathology, the symptomatology, and the principles of management of radiation-induced nephropathy, uretheritis, cystitis, and urethritis.

[Radiation cystitis : Pathophysiology and treatment]

Radiation cystitis (RC) is a common side-effect of radiation to the pelvis. Their clinical appearance as well as their degree of expression is manifold, as are the therapeutic options. However, in the absence of randomized examinations, recommendations are difficult. We differentiate between oral, systemic therapies, intravesical instillations and interventions as well as interventional, radiological and, as an ultima ratio, surgical treatments. This article provides an overview of the different treatment options with particular emphasis on the conservative-interventional therapy options.

Evaluating the Role of Urinalysis for Suspected Cystitis in Women Undergoing Pelvic Radiotherapy

PURPOSE

The aims of this study were to analyze the effectiveness of urinalysis parameters in predicting positive urine culture and to characterize urinary tract infections in gynecologic cancer patients receiving pelvic radiotherapy.

METHODS

The records of 134 women receiving pelvic radiotherapy were retrospectively analyzed with a total of 241 urine specimens. Dipstick, urine microscopy, and urine culture data were recorded. Sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratios of dipstick and microscopy components for predicting positive urine culture were calculated. Organisms isolated from positive cultures and their antibiotic resistance data were recorded.

RESULTS

A total of 84 urine cultures (34.9%) were positive for growth. The presence of either urine nitrites, leukocyte esterase, or both had the highest sensitivity (91.7%) of all tested parameters for predicting a positive urine culture. The presence of both urine white blood cells and urine nitrites had the highest specificity (95.5%), positive predictive value (75.0%), and diagnostic odds ratio (7.21 [2.92-17.83]), whereas the absence of urine white blood cells had the highest negative predictive value (87.0%). Escherichia coli was the most common grown in culture, isolated from 19 specimens (22.6%). When antibiotic sensitivity analysis was performed, 23.8% of pathogens were resistant to trimethoprim/sulfamethoxazole, 16.7% were resistant to ciprofloxacin, and 11.1% were resistant to nitrofurantoin.

CONCLUSIONS

Urinalysis may be less accurate for predicting urinary tract infection in women undergoing pelvic RT compared with the general population, but is still useful. Escherichia coli was less common than expected, and the rate of resistance to first-line antibiotics was relatively high, underscoring the importance of culture and sensitivity testing in order to confirm the efficacy of empiric antibiotic therapy.

Transurethral front-firing Greenlight bladder autoaugmentation for bladder contracture: technique and clinical outcomes

OBJECTIVE

To describe a novel transurethral front-firing Greenlight bladder autoaugmentation for the treatment of bladder contracture and report initial clinical outcomes.

METHODS

Between April 2014 and August 2015, five patients diagnosed with contracted bladder were all refractory to conservative treatment and received novel transurethral autoaugmentation. CT scan and urodynamics examination were conducted before operation for disease assessment. Mucosal and muscular layers of bladder wall in fundus were incised vertically and horizontally with front-firing Greenlight laser to enlarge bladder capacity in the operation. Imaging examination and periodical urodynamics study were performed to evaluate the clinical outcomes of the procedure in postoperative follow-up.

RESULTS

Transurethral front-firing Greenlight bladder autoaugmentation was performed successfully on all the patients. The mean operative time was 59 min (range 52-65 min) with no significant blood loss. Urodynamic parameters of these patients after operation improved significantly compared with those before operation. Average maximum cystometric capacity (Vmax) increased from 91.2 to 333 ml (p < 0.01), average maximum flow rate (Qmax) ascended from 12.6 to 18.62 ml/min (p < 0.01), and average flow rate (Q(ave)) also increased from 5.74 to 13.18 ml/min (p < 0.01). At the last follow-up, all the patients could void spontaneously with good bladder emptying and their symptoms improved significantly.

CONCLUSION

Our novel transurethral front-firing Greenlight bladder autoaugmentation is a safe and effective treatment for contracted bladders. Future studies with larger sample size and long-term follow-up are needed to confirm our findings.

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.

Intravesical Therapies for Radiation Cystitis

Objective

The purpose of this study was to summarize developments during the last decade in intravesical treatments for radiation cystitis. Radiation used to treat pelvic malignancies inadvertently damages the urinary bladder leading to acute as well as chronic symptoms. Late sequelae may take years to develop and include storage symptoms and hematuria, which may be life-threatening in severe cases. Conservative measures, surgical interventions, and systematically or intravesically administered agents represent treatment choices.

Methods

MEDLINE and PubMed were searched to retrieve clinical data on the subject, published in peer-reviewed journals from 2002 onwards.

Results

Historically referenced intravesical treatments such as aluminium salts and formalin, were not investigated in recent studies. The replenishment of the glycosaminoglycan layer of the bladder mucosa shows promise in reducing acute symptoms and possibly long-term bladder damage, but needs further investigation. Botulinum toxin also represents a new alternative treatment for radiation cystitis but its mechanism of action and efficacy should be evaluated in future trials.

Conclusion

There is a paucity of data in recent literature regarding the management of radiation cystitis, at least by means of intravesical agents. The replenishment of the glycosaminoglycan layer of the bladder mucosa and the administration of botulinum toxin show promise, but need further investigation.

Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitis due to carcinoma cervix: a study from a tertiary care hospital in South India

BACKGROUND

To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy.

METHODS

Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis.

RESULTS

Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature.

CONCLUSION

In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, cost-effective approach with good quality of life and early return to normal activity.

Combined Y-shaped common channel transureteroureterostomy with Boari flap to treat bilateral long-segment ureteral strictures

BACKGROUND

Ureteral stricture is a complication of several etiologies including idiopathic retroperitoneal fibrosis, infection, radiotherapy, instrumentation, and surgical procedures. A variety of techniques have been reported for management. The transureteroureterostomy and bladder flap have been the standard procedures for repairing distal ureteral defects of unilateral ureter. Bilateral ureteral stricture is an uncommon condition that challenges usual reconstructive procedures. It is a difficult task to reconstruct the complex situation of bilateral ureteral strictures.

CASE PRESENTATION

A 54-year-old female underwent concurrent chemoradiotherapy for stage IVB squamous cell carcinoma of cervix. Subsequently, she had stricture of bilateral distal ureters with bilateral hydroureteronephrosis which was found by computed tomography. The renal function deteriorated during the follow-up period. She had periodic change of double-J stents and percutaneous nephrostomy. However, the renal function still deteriorated. We performed a combined Y-shaped common channel transureteroureterostomy with Boari flap to reconstruct bilateral long-segment ureteral strictures. The patient recovered uneventfully.

CONCLUSION

Reconstruction of bilateral ureteral strictures is a difficult treatment. We developed a modified technique for the complex situation of bilateral ureteral strictures. To our knowledge, this has not been previously reported in the scientific literature and it is a feasible procedure to treat bilateral long-segment ureteral strictures.

Intravesical Hyaluronic Acid and Chondroitin Sulphate Improve Symptoms and Quality of Life in Patients with Late Radiation Tissue Cystitis: An Investigative Pilot Study

Intravesical hyaluronic acid (HA) and chondroitin sulphate (CS) instillation are effective for urinary tract infections (UTIs) and bladder pain syndrome. This study aimed to evaluate the tolerability, safety and efficacy of intravesical HA and CS instillation in patients with late radiation tissue cystitis (LRTC). In this pilot study, tolerability was reported as discontinuation or deviation of the protocol, safety as general or local side effects, efficacy as improvement of bladder capacity and frequency, quality of life (QoL) through the European Quality of Life 5-Dimensions (EQ-5D) (details at http://www.controlled-trials.com/ISRCTN37534393 ). Thirty-two patients with LRTC were enrolled. Twenty-seven patients (84.8%) received a mean of 12.2±0.3 months of instillation therapy. Only two patients (6.2%) developed a urinary tract infection from instillation, which required antibiotic treatment, nevertheless not compromising the therapy schedule. No male patient developed a urethral stricture. Intravesical instillation was associated with a significant increase (>50%) of bladder capacity from baseline (66.9ml) both at 3 months (101.9ml; p<0.001) and 12 months (174.4 ml; p<0.001). EQ-5D index significantly increased from baseline to both 3 and 12 months (0.26, 0.69 and 0.96, respectively; p<0.001). Intravesical co-administration of HA and CS improved bladder function, symptoms and QoL in patients with LRTC.

New insights for pelvic radiation disease treatment: Multipotent stromal cell is a promise mainstay treatment for the restoration of abdominopelvic severe chronic damages induced by radiotherapy

Radiotherapy may induce irreversible damage on healthy tissues surrounding the tumor. It has been reported that the majority of patients receiving pelvic radiation therapy show early or late tissue reactions of graded severity as radiotherapy affects not only the targeted tumor cells but also the surrounding healthy tissues. The late adverse effects of pelvic radiotherapy concern 5% to 10% of them, which could be life threatening. However, a clear medical consensus concerning the clinical management of such healthy tissue sequelae does not exist. Although no pharmacologic interventions have yet been proven to efficiently mitigate radiotherapy severe side effects, few preclinical researches show the potential of combined and sequential pharmacological treatments to prevent the onset of tissue damage. Our group has demonstrated in preclinical animal models that systemic mesenchymal stromal cell (MSC) injection is a promising approach for the medical management of gastrointestinal disorder after irradiation. We have shown that MSCs migrate to damaged tissues and restore gut functions after irradiation. We carefully studied side effects of stem cell injection for further application in patients. We have shown that clinical status of four patients suffering from severe pelvic side effects resulting from an over-dosage was improved following MSC injection in a compationnal situation.

Diagnostically challenging cases: what are atypia and dysplasia?

This article addresses the spectrum of atypia and dysplasia within the bladder epithelium and the diagnostic categories developed to further classify challenging lesions. In addition, the effects of inflammation, specific therapies, and instrumentation on the bladder mucosa as well as the associated difficulty in achieving the appropriate diagnosis are also discussed.

Nutritional supplementation with L-arginine prevents pelvic radiation-induced changes in morphology, density, and regulating factors of blood vessels in the wall of rat bladder

PURPOSE

To determine whether L-arginine has protective effects against radiation-induced alterations in the morphology and regulatory factors of vesical blood vessels in rats.

METHODS

Male rats aged 3-4 months were divided into groups of 10 animals each: (a) controls, consisting of non-treated animals; (b) radiated-only rats; and (c) radiated rats receiving L-arginine supplementation. Radiation was in one session of 10 Gy and was aimed at the pelvic-abdominal region. L-arginine was administered once a day (0.65 g/kg body weight), starting 7 days before radiation and continuing until killing on the 16th day after radiation. The density, relative area, and wall thickness of blood vessels were measured in the vesical lamina propria using histological methods, and the expression of vascular endothelial growth factor (VEGF) and fibroblast growth factors (FGF) in the bladder wall was assessed by RT-PCR.

RESULTS

Compared with controls, radiation alone decreased the density and relative area of blood vessels by 32 % (p < 0.01) and 25 % (p < 0.05), respectively, and reduced the arterial wall thickness by 42 % (p < 0.004). VEGF and FGF mRNA levels after radiation were diminished by 67 % (p < 0.002) and 56 % (p < 0.04), respectively. The radiated animals supplemented with L-arginine were not significantly different from controls.

CONCLUSIONS

Pelvic radiation leads to significant vesical modifications, as in the morphology of blood vessels and in VEGF and FGF expression. All these changes, however, were prevented by L-arginine treatment. These results emphasize, therefore, the potential use of this amino acid as a radioprotective drug.

Contracted bladder developing after prostate brachytherapy

This report describes an extremely rare case of severely contracted bladder developing after prostate brachytherapy. In April 2001, a 76-year-old man initially presented to our hospital for weak urinary stream. The patient was diagnosed with and treated for benign prostatic hyperplasia. During follow up, prostate-specific antigen level was elevated. In November 2005, the patient underwent transrectal prostate biopsy. Pathology showed adenocarcinoma, Gleason score 3 + 4 = 7. The patient was diagnosed with stage cT1cN0M0 prostate cancer. In January 2006, he underwent brachytherapy for prostate cancer. The procedure of brachytherapy was uneventful and the patient was discharged without any problems. Four months after the implant, the patient was admitted to our hospital for deterioration of kidney function as a result of a contracted bladder. Urinary culture of tuberculosis was negative and urinary cytology was class II. A urethral catheter was indwelled and the patient has been followed every month for catheter replacement. Bladder capacity is now less than 5 mL.

Intravesical bacillus Calmette-Guerin immunotherapy after previous prostate radiotherapy for high-grade non-muscle-invasive bladder cancer

OBJECTIVES

Intravesical bacillus Calmette-Guerin (BCG) immunotherapy is a standard treatment for high-grade non-muscle-invasive bladder cancer (NMIBC). We evaluated outcomes of BCG therapy for NMIBC in patients with a previous history of prostate cancer (CaP) radiotherapy (RT).

MATERIALS AND METHODS

A retrospective review of patients with a history of CaP RT who subsequently underwent treatment with intravesical BCG for high-grade NMIBC was performed. Patients were categorized as "BCG success" or "BCG failure" (defined as stage progression or recurrent/persistent disease). We evaluated factors related to the radiotherapy (type, interval to BCG), bladder cancer (clinical stage, immunotherapy type, and course), and patient comorbidities, to identify factors associated with BCG failure.

RESULTS

From 1996 to 2008, 26 patients with high-grade NMIBC received intravesical BCG immunotherapy after CaP RT. At a mean follow-up of nearly 5 years, 13 patients (50%) were successfully managed with one or more induction courses of BCG with or without the addition of interferon alpha. Twelve (46%) eventually required cystectomy for disease recurrence or progression, of which half had pathologically advanced disease (≥pT3). Clinical stage was similar between BCG success and failure patients (P = 0.40). Those who failed immunotherapy were more likely to have had a longer interval between RT and BCG induction (5.8 vs. 2.4 years, P = 0.02).

CONCLUSION

Approximately 50% of patients with NMIBC who were previously exposed to prostate radiation had a durable response to intravesical BCG. For non-responders, extravesical progression was common.

Prophylactic vesical instillations with 0.2% chondroitin sulfate may reduce symptoms of acute radiation cystitis in patients undergoing radiotherapy for gynecological malignancies

Introduction and hypothesis

We studied the feasibility and efficacy of intravesical instillations with 40 ml chondroitin sulfate 0.2% solution to prevent or reduce acute radiation cystitis in women undergoing pelvic radiotherapy.

Methods

In a comparative pilot study in 20 patients, half of the patients received instillations. Instillations' bother was measured with visual analog scores (VAS, 0–10); bladder pain, with VAS; micturition-related quality of life, with the urogenital distress inventory (UDI).

Results

One of the instilled patients discontinued the instillations. The first median “acceptability”-VAS was 0 (range, 0–3); the last median was 1 (range, 0–3). “Bladder pain”-VAS peaked halfway in the treatment among controls (median, 1; range, 0–5) and after treatment in the instilled patients (median, 1; range, 1–3). UDI scores showed over time median follow-up scores at or above median baseline scores in controls and at or below median baseline scores in instilled patients.

Conclusion

Intravesical instillations with chondroitin sulfate 0.2% solution may decrease the bother related to bladder symptoms and are well tolerated.