Page 7 - CUA Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis

BPR: Radiation-induced hemorrhagic cystitis

therapies, as only alum irrigation has been shown to provide
Initial assessment and early management improvement within days of being started. HA and SPP both
treat urinary symptoms associated with hemorrhagic cystitis
Initial assessment Presenting with clots & retention in addition to hematuria.
• History and physical • Continuous bladder irrigation
• Laboratory evaluation if and hydration The third category, “Refractory and life-threatening hema-
• Axial imaging preferably CT Uro • Inpatient monitoring and
• Cystoscopy ± fulgerization transfusion as indicated turia,” includes patients who have previously been trialed
• Cystoscopy, clot evacuation ± and failed with treatment options from groups 1 and 2, and
fulgerization
continue to have symptomatic hematuria that poses a threat
to their safety and well-being. In these patients, treatment
Persistent or recurrent clinically significant hematuria
options typically have a rapid onset of action and have been
proven to be effective, but may be associated with significant
morbidity to the patient. Less invasive procedures, such as
Intravesical alum HBOT HA or SPP
• Inpatient tx in those or • Inpatient or or • Outpatient in stable embolization or formalin instillation, should be attempted
without renal failure outpatient in stable patients, especially
patients those with significant prior to surgical therapy. Once a mainstay of treatment, and
LUTS commonly recommended in many former treatment algo-
rithms, we recommend caution with the usage of formalin
*For stable recurrent patients, multiple strategies and attempts may be used prior to
proceeding with more invasive and irreversible options instillations, with special care to limit contact time, use the
least concentrated formulation necessary, and to prevent sys-
Refractory and life-threatening hematuria temic uptake or refluxing into the upper tracts. Clinicians and
patients need to be aware of the high risk associated with cys-
Transarterial embolization Definitive surgical management tectomy in post-radiation patients before proceeding to surgi-
• Preference for selective or • Consideration for urinary
superselective embolization then diversion with or without cal intervention. In patients whom a cystectomy would not be
Formalin cystectomy based on appropriate, or with a limited life span, temporary diversion
• Limit contact, uptake, and reflux individual patient factors
with either percutaneous nephrostomy tubes or cutaneous
ureterostomies may be considered as an alternative.
Fig. 1. Treatment recommendations. CT Uro: computed tomography urogram;
HA: hyaluronic acid; HBOT: hyperbaric oxygen therapy; LUTS; lower urinary
tract symptom; SPP: sodium pentosan polysulfate; tx: treatment. Conclusion

rectable factors, such as infection, malignancy, or coagu- RHC remains a challenging medical condition that often
lopathies, should be treated if clinically possible. presents in a frail and vulnerable population. In this report,
The second group, patients with persistent or recurrent we have presented a general approach and suggestions for
clinically significant hematuria, may apply to those who management, as well as an overview of key research sup-
have required continuous bladder irrigation, irrigation, and porting specific therapies. These guidelines should always be
clot evacuation as an inpatient and continue to have hema- used in the context of an individual patient’s presentation,
turia, but also acknowledges that there are many patients and may continue to evolve, as more evidence becomes
who have recurrent hematuria that is clinically significant available on the subject.
who may benefit from treatment as an outpatient. The defini-
tion of “clinically significant” here may be broadly applied Competing interests: Dr. Saad reports personal fees and research grants from Amgen Inc, Astellas,
to any gross hematuria that is causing a marked burden Bayer, Janssen, and Sanofi. Dr. Lukka is a speaker for Astellas; has received grants and/or honoraria
on patients or negatively impacting their day-to-day living. from Abbvie, Actavis, Amgen, Astellas, Bayer, Ferring, Janssen, Sanofi, and Tersera; owns stock
Treatments recommended for patients in this group have and options in Vertex Pharmaceutical; and has participated in clinical trials supported by Bayer
been shown to be effective, safe, and well-tolerated by most and Janssen. Dr. Kapoor has been an advisor for and has participated in clinical trials supported
by Amgen, Astellas, GSK, Janssen, Novartis, Pfizer, and Sanofi. The remaining authors report no
patients. The four recommended treatment options here competing personal or financial interest related to this work.
were chosen because they have evidence replicated from
multiple centres, are clinically available in Canada, and
have been approved and proven in comparable patholo- This paper has been peer-reviewed.
gies. As more research continues to be done on radiation
cystitis, we may be able to add further therapies to this
group. HBOT is offered here as initial therapy to reflect the
growing amount of evidence that suggest it is an effective References
and safe treatment for RHC, including in those presenting
with high-grade toxicities. Within this group, a clinician 1. Marks LB, Carroll PR, Dugan TC, et al. The response of the urinary bladder, urethra, and ureter to radiation
may consider onset of action as a deciding factor between and chemotherapy. Int J Radiat Oncol Biol Phys1995;31:1257-80. https://doi.org/10.1016/0360-
3016(94)00431-J

CUAJ • February 2019 • Volume 13, Issue 2 21