Post-irradiation cystitis improved by instillation of early placental extract in saline

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.

[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.

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.

Management of radiation cystitis

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

The management of haemorrhagic cystitis with sodium pentosan polysulphate

OBJECTIVE

To assess the use of sodium pentosan polysulphate (SPP) for haemorrhagic cystitis (HC), a potentially life-threatening side-effect in patients treated with pelvic radiotherapy or cyclophosphamide, and which can be difficult to manage as patients often have significant comorbidity.

PATIENTS AND METHODS

Between September 1991 and December 2000, 60 consecutive patients (24 women and 36 men) with haemorrhagic cystitis were primarily treated with SPP; 53 patients had had radical radiotherapy for pelvic malignancy and seven systemic cyclophosphamide. All patients were screened for blood dyscrasia and residual/primary urothelial malignancy with imaging, urine cytology and cystoscopy.

RESULTS

In all, 51 patients were available for follow-up; the median (range) interval between completing treatment and developing haematuria was 4.5 (0.08-39.4) years, the duration of treatment 180 (21-1745) days and patients were followed for 450 (19-4526) days from the onset of haematuria. All patients were started on SPP at an initial dose of 100 mg three times daily. In 21 patients the dose was gradually reduced to a maintenance dose of 100 mg and in 10 further patients SPP was stopped because the haematuria stopped completely. Twenty patients died while on treatment from causes not directly related to their haematuria.

CONCLUSION

We recommend the use of SPP as the primary method of managing haemorrhagic cystitis associated with pelvic radiotherapy or systemic chemotherapy.

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.

The Treatment of Long-Standing Venous Ulcers with an Extract of Early Placenta – a Pilot Study

The human placenta and its membranes have been used intermittently as wound dressings for more than 70 years. Term placenta is known to contain a number of growth factors essential to the healing process. The intense physiological activity of early placenta suggested that it should have similar attributes and we tested this hypothesis on one of the most refractory of all wounds – ulcers caused by chronic venous insufficiency.

The cytosol fraction of 6–8 week placenta was incorporated under sterile conditions into an inactive cream vehicle and applied daily to the ulcer. The preparation and quality control of this extract are described.

Eighteen patients were treated in this pilot study. The chronicity of the ulcers varied from 12 weeks to 30 years, and all had previously received conventional therapy. Ten patients with bilateral ulcers had treatment with the test preparation on one side only thereby serving as their own controls. Granulation tissue appeared between the 7th and 17th day after starting treatment, and epithelialization began within 2 weeks thereafter. The preparation produced complete healing in all cases and took 12 to 24 weeks, depending on ulcer size. None of the untreated ulcers were closed at the end of the trial. No breakdown has been seen so far on follow-up.

The healing effect suggests that trophoblast might supply the missing factor(s) normally operative in surgical wounds and uninfected traumatic wounds.