Hemorrhagic radiation cystitis. Treatment

The management of cyclophosphamide-induced haematuria

Haemorrhagic cystitis is a frequent complication of treatment with cyclophosphamide. It remains a difficult clinical problem to treat, compounded by the frailty of patient. Furthermore, the preventative measures and treatments available for CP-induced haematuria have their own benefits and disadvantages.

Risk factors and treatment of hemorrhagic cystitis in children who underwent hematopoietic stem cell transplantation

A retrospective cohort of 163 children with 171 hematopoietic stem cell transplantation (HSCT) performed during Mar. 1992-Dec. 2005 were analyzed to evaluate the incidence, risk factors, management, and outcome of hemorrhagic cystitis (HC). Fourteen patients (8.2%) developed HC (6 boys, median age 6.6 years) at 0-166 days after HSCT (median 25 days), and lasted for 3-96 days (median 26 days). Older age at transplant (median 11.0 vs. 6.4 years, P = 0.013), allogeneic transplant (OR = 4.4, P = 0.02), cyclophosphamide-containing conditioning (OR = 4.87, P = 0.008), moderate-to-severe acute graft-versus-host disease (GVHD) (OR = 3.56, P = 0.025) and hepatic GVHD (OR = 3.62, P = 0.017) were associated with higher risks of HC in univariate but not multivariate analyses. While estrogen was ineffective in most patients, intravesical formalin, which was used in five patients, was found to be a very effective yet safe treatment for intractable HC. Patients with HC had longer hospital stay (median 175 vs. 88 days, P = 0.004). HC resolved after treatments in all cases but eight of the 14 patients subsequently died of other complications of HSCT. In conclusion, HC is a serious complication of allogeneic HSCT. Treatment with intravesical formalin appears effective and safe and can be considered early in severe HC to reduce the risk of morbidity and mortality.

Non-surgical interventions for late radiation cystitis in patients who have received radical radiotherapy to the pelvis

BACKGROUND

Chronic radiation cystitis occurs a minimum of three months after completion of pelvic radiotherapy and represents a range of clinical symptoms for which there is as yet no recommended standard management.

OBJECTIVES

The aim of this review was to identify the various non-surgical treatment options for the management of late chronic radiation cystitis and evaluate the evidence.

SEARCH STRATEGY

Synonyms for radiation therapy and for the spectrum of radiation toxicity to the bladder in both text and MeSH terms were combined and applied to a range of databases without restriction of year of publication, methodology or language.

SELECTION CRITERIA

The inclusion criteria included studies of interventions for the non-surgical management of all grades of late radiation cystitis.

DATA COLLECTION AND ANALYSIS

Out of 80 relevant studies, there were no RCTs that met the inclusion criteria, but there were three prospective case series and two non-randomised studies which assessed different interventions and were not comparable.

MAIN RESULTS

Sixty-three reports met the stated inclusion criteria. The majority were predominantly retrospective case series with the exception of two trials which were unrandomised and unblinded studies with a control group for comparison of effect. Although these two trials, Micic 1988, (intravesical placental extract) and Milani 1988, (flavoxate) provided the strongest evidence they were not randomised and were essentially isolated controlled studies.

REVIEWER'S CONCLUSIONS

In such a relatively rare condition there are obvious difficulties in identifying sufficient patients to participate in a randomised controlled trial. The number of published reports is a reflection of the degree of medical interest that exists in providing therapeutic solutions for late radiation cystitis. However, in spite of the two studies of level IIA evidence, the absence of randomised controlled trials makes it impossible to draw any firm conclusions.

Massive haemorrhage of inoperable bladder carcinomas: treatment by intravesical formalin solution

Numerous modalities of treatment have been used in the past to control massive bladder haematuria, with varying degrees of success. Formalin has been used in urology only for the treatment of intractable haematuria of inoperable bladder carcinomas, usually as the last resort when all other nonsurgical attempts have failed and before more aggressive surgical measures are considered. Eight patients with bladder tumours classified T2 (2 cases), T3 (2 cases) or T4 (4 cases) and 2 patients with radiation cystitis were assessed as being beyond the scope of even palliative surgery, severe haemorrhage being present in all cases. The treatment was instituted in all cases by intravesical instillation of a 10 per cent formalin solution under general anaesthesia. Four patients received 4 and 6 instillations, respectively, the former over 4 weeks and the latter over 10 months. The bladder was filled completely and an indwelling-catheter introduced, the formalin solution being left in the bladder for 5 to 30 min (mean: 12 min). Haematuria was absent after 1 to 25 days (mean: 11 days) in 9 cases. The 10th patient died before arrest of haemorrhage. Survival after instillation was 65 days to 27 months (mean: 11.5 months). The outcome was fatal within 4 months or less in 3 cases and 4 patients died of renal failure within 3 months, one within 65 days after instillation. In 4 cases, treatment with formalin reduced bladder capacity to less than 100 ml. Other complications included retroperitoneal fibrosis (1 case), urinary incontinence (3 cases) and severe frequency and nocturia (3 cases). This procedure should therefore be reserved for terminal cases unable to support more aggressive therapy.

Oral conjugated estrogen therapy for treatment of hemorrhagic cystitis

We report 7 cases of severe hemorrhagic cystitis that required repeated transfusions, surgical intervention and oral conjugated estrogens. Of these 7 cases hematuria resolved completely in 5 during estrogen therapy and decreased sufficiently in 1 to preclude further transfusion. We found conjugated estrogens to be an effective, simple, inexpensive, well tolerated and readily available treatment for hemorrhagic cystitis.

Intravesical formalin for hemorrhagic cystitis following irradiation of cancer of the cervix

OBJECTIVE

To determine the effectiveness of intravesical formalin instillation in hemorrhagic cystitis following irradiation of cancer of the cervix.

METHOD

Records were reviewed for 35 patients with hemorrhagic radiation cystitis who underwent treatment with 1% (n = 22), 2% (n = 10), and 4% formalin (n = 4), using Fair's technique.

RESULT

Complete response was seen in 31 patients (89%) and partial response in 3 patients (8%) after a single instillation. Minor complications were seen in 19 patients (54%). Major complications occurred in 11 patients (31%), with 5 cases requiring subsequent urinary diversion. One patient died of persistent bleeding and probable formalin toxicity. Hematuria recurred in 7 patients achieving complete response at a mean period of 8 months after treatment. A 1% solution was as effective in controlling hematuria as higher concentrations and was associated with significantly less morbidity.

CONCLUSION

Intravesical instillation of 1% formalin is an effective treatment for intractable hematuria secondary to radiation cystitis.

Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen

Five patients with severe hemorrhagic cystitis induced by radiation and/or cyclophosphamide were systematically treated with conjugated estrogen. Two patients received conjugated estrogen twice each day (1 mg. per kg.) intravenously, followed on day 3 and thereafter by 5 mg. per day orally. Hematuria decreased markedly 6 to 8 hours after the initial dose and urine color became light yellow within 1 to 3 days. The other 3 patients received 5 mg. conjugated estrogen per day orally and urine color became clear within 4 to 7 days. Hematuria did not recur during 12 to 22 months in 4 patients who received daily conjugated estrogen (1.25 mg.). However, transient episodes of mild hematuria persisted in 1 patient during the 3-month followup despite a higher dose of conjugated estrogen (10 mg. per day). Complications, including thromboembolism and other side effects associated with conjugated estrogen, were not observed in these patients. We postulate that conjugated estrogen controls hematuria in hemorrhagic cystitis by decreasing the fragility of the mucosal microvasculature of the bladder.

Hemorrhagic cystitis: a review

Acute, fulminant bladder hemorrhage usually is seen at tertiary care centers in which cancer patients are treated with oxazaphosphorine alkylating agents, particularly cyclophosphamide and isophosphamide. These agents also are used to treat benign conditions, such as lupus erythematosis and Wegener's granulomatosis. Radiation effects from treatment of prostatic or cervical carcinoma can appear for the first time as late as 15 to 20 years after initial treatment. Other iatrogenic causes of bleeding include treatment with penicillins and, rarely, danazol. Occasionally, bladder hemorrhage may be the presenting sign of metabolic disease, such as secondary amyloidosis in rheumatic arthritis. Cases of mild to moderate hemorrhagic cystitis arising in the otherwise healthy patients should lead one to pursue the possibility of environmental toxins, accidental poisoning, recreational drug use or viruses. In all cases the diagnosis should be reserved until more common causes of hematuria, such as bacterial or fungal infection, stones, cysts or tumors, have been ruled out. Prevention of chemotherapeutically induced cystitis ideally will follow careful attention to adequate hydration and the prophylactic use of antitoxins, such as mesna. Treatment, as outlined previously, consists of a series of measures beginning with the most conservative. Intervention thereby is tailored to the gravity of the clinical situation.

The use of an alum irrigation in the treatment of massive bladder haemorrhage

Severe, massive bladder haemorrhage is a difficult and often frustrating clinical problem. The aetiologies are numerous and include irradiation, malignancy, severe infection and drug-induced changes. Among the numerous modalities of treatment that have been reported formalin, phenol and silver nitrate instillations have often been associated with significant side effects, morbidity and mortality and have had varying degrees of success. During the last two years we have used continuous closed irrigation of a sterile 0.5% alum solution in 16 patients. Alum is an astringent and acts by protein precipitation over the bleeding surface. Because of a low cell permeability its action is limited to the cell surface and interstitial spaces. The permeability of the cell membrane is reduced but remains viable. The preparation and the pharmaceutical aspects of the 0.5% alum irrigation will be discussed. The conclusion is that the technique of managing massive bladder haemorrhage is simple, efficient, nontoxic and less expensive than previously reported therapies. Therefore, irrigation with alum before instituting invasive means to control bleeding is recommended.

Intravesical formalin for hemorrhagic cystitis: analysis of therapy

In an extensive search of the literature 235 cases of intractable hemorrhagic cystitis treated with intravesical formalin were identified. Effectiveness of therapy, rate of recurrence of hematuria, morbidity and mortality were analyzed with respect to concentration of formalin and to the etiology of hematuria. Increasing concentrations of formalin slightly improved effectiveness of therapy and reduced the rate of recurrence of hematuria. However, this often resulted in an increase in morbidity. When patients were categorized according to the etiology of intractable hematuria it was noted that lower concentrations of formalin were effective in controlling hematuria caused by either cyclophosphamide cystitis or unresectable carcinoma of the bladder. In contrast, higher formalin concentrations were required to control bleeding due to radiation cystitis.

Renal and urinary tract complications following the intravesical instillation of formalin

The case is reported of a 10-yr-old girl who developed intractable hematuria from hemorrhagic cystitis following chemotherapy for a malignant lymphoma. Following the intravesical instillation of formalin, which controlled the hematuria, she developed oliguria attributable to ureteric stenosis and fibrotic contraction of the renal pelves. Bilateral nephrostomies were constructed, but recurrent pyelonephritis and further renal pelvic obstruction developed. A series of renal biopsies and ultimately bilateral nephrectomy revealed severe, chronic interstitial nephritis, massive renal interstitial accumulation of deposits probably containing Tamm-Horsfall protein and, in the left nephrectomy specimen, a florid interstitial chronic granulomatous inflammatory reaction. Although ureterohydronephrosis has been described by others as a complication of the intravesical instillation of formalin, fibrotic contraction of the upper urinary tract and the florid interstitial nephritis with granulomata as described herein have not previously been reported. It is proposed that vesicoureteric reflux of formalin, perhaps accompanied by intrarenal reflux, caused or contributed to these pathological changes.

Treatment of radiation cystitis with hyperbaric oxygen

A patient with severe radiation cystitis resistant to current therapy was treated with hyperbaric oxygen to facilitate closure of a vesicocutaneous fistula. In addition to the fistula healing, her symptoms of radiation cystitis have not recurred for over a year and a half.

Intractable hematuria and formalin

Massive hematuria, which is most frequently caused by radiation for pelvic malignancies, after treatment with cyclophosphamide or secondary to aggressive anticoagulation, represents a vexing problem for the practicing urologist. The existence of numerous therapeutic approaches results from the lack of an effective therapeutic modality. Lately, formalin seems to offer a new hope for the treatment of intractable hematuria. Analysis of published results after treatment with formalin revealed generally excellent results regarding control of hematuria. Nevertheless, the complication rate of formalin application is surprisingly high, including vesicoureteral reflux and hydroureteronephrosis as local reactions and systemically tubular necrosis with anuria. Our series of patients is presented with a detailed description of a patient who was afflicted with a vesicovaginal fistula following formalin instillation. Formalin can serve as excellent therapy for massive hematuria. If attention is paid to the concentration and to the technical details of its instillation the noxious side effects can be minimized or prevented in the majority of cases.

Topical levarterenol in control of bladder hemorrhage

Topical levarterenol was evaluated for the control of bladder hemorrhage. Its possible toxic effects were investigated in the intact dog bladder, and its use was compared with saline irrigations in experimental massive bladder hemorrhage. Eight mg.% levarterenol was found to be safe and effective in our model.

Urologic complications of pelvic irradiation

We evaluated 964 patients who had undergone radiation therapy for malignant disease of the pelvic viscera during a 5-year period and who ahd been followed for 5 to 10 years after completion of treatment. Therapy had been given for gynecological tumors in 493 cases, genitourinary tumors in 240 cases, bowel tumors in 172 cases and various other malignant tumors in the pelvis in 59 cases. The incidence of cystitis, hematuria, ureteral obstruction and fistula formation was determined for each group. There were 203 urological complications, an incidence of 21 per cent, but only 25 of these complication (2.5 per cent) could be ascribed to the effects of radiation alone, the remainder being associated with persistent or recurrent tumor. Approximately 20 per cent of the patients had some abnormalities detected in the pre-treatment excretory urogram. The development of urologic complications was related to the radiation dosage and previous bladder operations.

Formalin treatment for intractable hemorrhagic cystitis: a review of the literature with 16 additional cases

Acute, exsanguinating hemorrhagic cystitis secondary to cyclophosphamide therapy, radiation therapy, or an infiltrating bladder tumor may be managed successfully with intravesical Formalin therapy. The indications for its use, the technique, success rates, and complications are discussed. This treatment was effective in 14 of 16 patients in the present series and 79 of 90 cases reported in the literature. Dilutions of 4% or less were as effective as a 10% dilution and were associated with far fewer complications. The early use of Formalin in the treatment of intractable hemorrhagic cystitis is recommended.

Effects of formalin on bladder urothelium

Formalin instillation into canine bladders was followed by serial radiographic and histologic evaluation. A generalized slough of epithelial tissue was seen with the deposition of an amorphous substance. Telangiectasia resulted in moderate bleeding. No ureterovesical junction obstruction was seen and reflux occurring in 60 per cent of the animals reverted to normal. Correlation with clinical experience is made.