Page 1 - CUA Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis

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CUA BEST PRACTICE REPORT

Canadian Urological Association Best Practice Report: Diagnosis

and management of radiation-induced hemorrhagic cystitis

George Goucher, MD ; Fred Saad, MD ; Himu Lukka, MD ; Anil Kapoor, MD 1
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1 Department of Surgery (Urology) and Oncology, McMaster University, Hamilton, ON, Canada; Department of GU Oncology, l’Université de Montréal, Montreal, QC, Canada; Department of Radiation
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Oncology, McMaster University, Hamilton, ON, Canada

Cite as: Can Urol Assoc J 2019;13(2):15-23 http://dx.doi.org/10.5489/cuaj.5788
Background

Published online November 22, 2018 Hemorrhagic cystitis refers to a collection of symptoms and
signs defined by hematuria, lower urinary tract symptoms
(LUTS), and cystoscopic findings indicative of underlying
Introduction urothelial damage. It can have a number underlying caus-
ative factors: treatment with chemotherapeutic agents (such
as cyclophosphamide and concurrent therapies); post-trans-
Methodology plant patients; infection-mediated; treatment with radiation
therapy. RHC is often an adverse event in patients with pre-
A comprehensive review of studies examining radiation- vious radiation to the pelvis for urological or gynecological
induced hemorrhagic cystitis was performed using PubMed, malignancy and will be the focus of this BPR.
Medline, and the Cochrane Library database. The bibliogra- RHC is generally considered a separate pathologial pro-
phies of relevant articles were searched to avoid exclusion cess from acute radiation effects, with early signs of uro-
of meaningful articles. Where available, focus was given to thelial effects occurring at three months and pathological
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systematic reviews and comparative studies; however, due changes occurring 6‒12 months after radiation. New-onset
to a lack of high-quality evidence, case series were included symptoms have been recorded up to 20 years after radiation
and made up the majority of articles included. All articles treatment. The estimates for prevalence of RHC after radia-
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were reviewed using the evidence-based medicine levels, tion treatment varies widely depending on the diagnostic
with a modified Oxford grading system for recommendations. definitions used, but different studies have quoted them as
9‒21% following treatment of prostate cancer, 3‒6.7% for
Objective cervical cancer, and 2‒47% for bladder cancer. The use of
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modern treatment techniques, such as intensity-modulated
This Best Practice Report (BPR) seeks to inform and educate radiation therapy and volumetric modulated arc therapy,
readers on radiation-induced hemorrhagic cystitis (RHC), as have reduced the radiation dose to the bladder. Randomized
well as a survey of commonly used treatment options avail- studies have shown that the use of higher doses in the man-
able and the evidence available to support a given therapeu- agement of prostate cancer have resulted improved prostate-
tic choice. The primary outcome of interest was resolution specific antigen (PSA) control using these modern treatment
of hematuria; where available, the effects of treatment on techniques, but with the same incidence of late complica-
urinary symptoms are shared. A relative absence of com- tions. There has also been a trend to using hypofraction-
parative data has prevented previous reviews from providing ation radiotherapy regimens (higher dose per fraction given
firm guidelines in the management of RHC and this report over a shorter timeframe). To minimize late bladder effects,
relies heavily on retrospective case series with methodologi- emphasis needs to be paid to ensuring doses received by
cal limitations to form recommendations. Individual patient radiovulnerable structures, such as bowel and bladder, are
factors, available resources, and new research will continue kept within acceptable limits.
to shape clinical decision-making. The exact mechanism by which radiation causes damage
to the bladder is not entirely understood, but believed to be
multifactorial. While direct damage to DNA is believed to be

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