Radiation-induced Hemorrhagic Cystitis Research Articles

Radiation-induced haemorrhagic cystitis after prostate cancer radiotherapy: factors associated to hospitalization and treatment strategies.

BackgroundLate onset of radiation-induced haemorrhagic cystitis (RHC) after radiation therapy (RT) for prostate cancer (PCa) may present or evolve severely, requiring hospitalization with invasive interventions. In the present study, we have analysed the prevalence and risk factors associated with the onset of RHC.MethodsFrom January 2002 to May 2017, 1421 patients undertook RT for PCa as a primary, adjuvant, or salvage treatment option. RHC presented in 5.6% (n = 80) of the patients; the diagnosis was based on clinical and endoscopic characteristics. Variables in observation included patients, tumours, and RT-dosimetry characteristics. Patients with a previous history of bladder cancer were excluded. Univariate (Student t/Chi square) and uni-/multivariate Cox regression analysis were performed; the events and time-points were hospitalization and time-to-event, respectively.ResultsThere were 80 patients with a mean age at RT of 70.1 years (SD 6.4), mean time lag to RHC of 43.9 months (SD 37.5). Median Emergency attendance was two and three times for patients without/with hospitalization, respectively. There were in total 64 admissions with invasive treatment required in 26/36 (72.2%) of the patients hospitalised, including transurethral fulguration in 22 and radical cystectomy in 5. Patients at higher risk of hospitalization were those undertaking antiplatelet/anticoagulant treatment (HR:3.30; CI 95%:1.53–3.30; p = 0.002) and those treated with salvage RT with higher bladder volume receiving >70 Gy (bladder V70) (HR:1.03; CI 95%:1.01–1.05; p = 0.027). At receiving operating characteristic analysis, the cutoff for bladder V70 was 29%.ConclusionNearly half of patients presenting RHC may require invasive treatment including cystectomy. Risk factors associated with hospitalization are patients undertaking antiplatelet/coagulant treatment and bladder V70 > 29% in salvage RT patients.

Oxígeno hiperbárico para la cistitis inducida por radioterapia: un seguimiento a largo plazo

Introduction and objectivesBladder complications may be seen in up to 12% of patients treated with pelvic irradiation. Hyperbaric oxygen therapy (HBOT) is an option for the management of radiation-induced hemorrhagic cystitis (RIHC). The aim of this study was to evaluate the efficacy of HBOT in radiation cystitis and to identify the predictive factors for a successful outcome. Material and methodsWe retrospectively reviewed 105 patients diagnosed with RIHC which were treated with HBOT between 2007 and 2016 in our institution. Patients received 100% oxygen in a multiplace hyperbaric chamber at 2.4atm for 80minutes. All patients fulfilled a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period. ResultsAfter a median of 40 HBOT sessions, there was success rate of 92,4% in the control of hematuria. During our follow-up period (median of 63 months) 24,7% patients presented with recurrence of hematuria. The mean score of the questionnaire-assessed variables: dysuria, urinary frequency and hematuria, was significantly lower after the follow-up period (P<.05).Our data shows that the sooner HBOT is delivered after the first episode of hematuria, better response rates are achieved and lower recurrences concerning hematuria were registered (P<.05). No serious complications were observed. ConclusionsOur results support the safety and long-term benefits of HBOT on RIHC and other distressful bladder symptoms, which represents an expected improvement of quality of life in our patients.

Outcome of a 980-nm diode laser coagulation in women with radiation-induced hemorrhagic cystitis: a single-center retrospective study.

The purpose of this study was to evaluate the efficacy of a 980-nm diode laser coagulation in women with radiation-induced hemorrhagic cystitis (RHC). We conducted a retrospective study of 21 RHC patients treated with a 980-nm diode laser between July 2014 and December 2017 at our institution. Data was collected with regard to age, sex, lower urinary tract symptoms, use of transfusions, a drop in hemoglobin levels, indication of radiotherapy, median time between radiation therapy and presentation, previous treatments, operative time, mean energy used, number of coagulated areas, catheterization time, discharge time after treatment, hospital stay, and surgical outcome. All 21 patients were women with a median age of 52years (range 36-68years). Eighteen patients complained of frequency and urgency, four patients had dysuria, and one patient developed urinary retention. Radiation therapy was primarily indicated in the treatment of cervical cancer in 18 patients (85.7%) and endometrial cancer in three patients (14.3%). Nine patients (42.8%) received blood transfusion before surgery and three patients (14.3%) needed blood transfusion after the procedure. The mean decrease in hemoglobin prior to the procedure was 4.08 ± 2.04g/dL. The median length of time from completion of radiotherapy to the presentation of hematuria was 38months (range 8-65months). All patients had failed an adequate trial of conservative treatment which included adequate hydration, hemostatics, continuous bladder irrigation (CBI), and clot evacuation at the bedside. Eleven patients (52.4%) had previously been treated with endoscopic electrocoagulation; the mean number of procedures was 1.73 ± 0.78 (range 1-3 sessions). Six patients (28.6%) underwent HBO, and sodium hyaluronate solution irrigation was administered to 3 patients (14.3%). The mean number of HBO sessions was 26.3 ± 16.8 (range 8-50), and the mean number of sodium hyaluronate solution irrigation procedures was 4.33 ± 1.53 (range 3-6). All operations were successful. The mean operative time was 45.6 ± 12.3min, the mean number of coagulated areas was 11.7 ± 4.4, the mean energy used was 2.74 ± 1.14kJ, the mean catheterization time was 6.2 ± 0.9days, the mean discharge time after treatment was 6.8 ± 1.2days, and the average length of a hospital stay was 7.4 ± 1.3days. In 16 patients (76.2%), hematuria was completely resolved after one session of diode laser coagulation. Four patients (19.0%) underwent multiple sessions of laser treatment due to recurrent gross hematuria (three patients required two sessions and one patient required three sessions). Only one patient (4.8%) who had persistent gross hematuria after diode laser treatment (two sessions) underwent a radical cystectomy, which resolved the hematuria. The median hematuria-free interval of patients who had multiple procedures was 9months (range 1-13months). In total, 21 patients underwent 27 sessions of diode laser coagulation, and the median hematuria-free interval was 16months (range 1-45months) with a median follow-up of 25months (range 7-48months). Our study shows promising results for the management of patients with RHC; however, further evaluation with a larger cohort is required to confirm the efficacy of this treatment.

IJU this issue

This issue of International Journal of Urology contains two Review Articles, eight Original Articles and six Urological Notes. Tanaka et al. (Osaka, Japan) reviewed the current topics and trends of hyperbaric oxygen (HBO) therapies in urological diseases. HBO therapy can be an effective option for treating some urological conditions, including radiation-induced hemorrhagic cystitis, Fournier gangrene and interstitial cystitis. In the past, there have been concerns about whether HBO could accelerate cancer cell growth through increased oxygen delivery. However, previous studies concluded that HBO did not promote cancer aggressiveness and that HBO was a safe treatment for cancer patients. This is good news for many urological physicians. Ito (Tokorozawa, Japan) reviewed recent advances in the systemic treatment of metastatic non-clear cell renal cell carcinomas (nccRCCs). At present, there is no standard treatment for metastatic nccRCCs. There are various types of nccRCCs with different genetic backgrounds and molecular features. Currently, tyrosine kinase inhibitors are a treatment option for metastatic papillary RCC as both first-line and second-line agents, whereas both tyrosine kinase inhibitors and mammalian target of rapamycin inhibitors can be applicable for metastatic chromophobe RCC. However, further evidence is required to clarify appropriate therapeutic strategies for nccRCC using new agents and combination regimens. In the Original Articles, Tohi et al. (Kobe, Japan) assessed the perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy for cT1b renal tumors compared with cT1a. They concluded that robot-assisted partial nephrectomy without renorrhaphy using the soft-coagulation system and absorbable hemostats appears to be feasible for cT1b tumors, although longer warm ischemic time and a high rate of complications can be expected compared with cT1a tumors. It is notable that pseudoaneurysm occurred in none of the 66 patients with cT1a tumors and only one of the 34 patients with cT1b tumors. Okumi et al. (Tokyo, Japan) investigated biopsy-proven recurrence rates and risk factors for immunoglobulin A nephropathy recurrence in 299 kidney transplant recipients. The 10-year recurrence rate was 34%. Related-donor transplantation and post-transplant increased proteinuria were identified as potential risk factors for recurrence. The results have clinical implications in that the signs of recurrent immunoglobulin A nephropathy should be evaluated carefully in recipients receiving related-donor transplants. In the Urological Notes, Suzuki et al. (Tokyo, Japan) reported penile size and stretched rate in a Japanese male population using fresh cadavers. This is a unique study. As Fukuhara (Osaka, Japan) described in the Editorial Comment, penile size is an important factor for men to have a better self-image and better satisfaction during sexual activity. This study provides on-demand helpful data to urologists, because there is scarce knowledge in this field. Yamada et al. (Kyoto, Japan) investigated the feasibility of virtual reality for surgical planning and intraoperative management in partial nephrectomy. Virtual reality technology allows the surgeon to understand the patient's anatomy more accurately and plan the surgical procedures with more care. Although the objective usefulness of the case-specific 3-D virtual reality-based surgical simulation is not shown, it can be a useful technique to intuitively understand surgical anatomy and facilitate surgical decision-making in partial nephrectomy. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of International Journal of Urology. None declared.

Incidence and Morbidity of Radiation-Induced Hemorrhagic Cystitis in Prostate Cancer

OBJECTIVETo determine if reported incidence rates of hemorrhagic cystitis after radiation therapy for prostate cancer are accurate, to investigate the effect of different radiation modalities on the development of hemorrhagic cystitis and to assess its morbidity and treatment. MATERIALS AND METHODSA retrospective chart review was completed of 709 patients at 2 Detroit Medical Center hospitals who underwent radiation therapy for prostate cancer between January 2000 and September 2015. In patients who developed hemorrhagic cystitis, we analyzed the incidence, radiation modality, morbidity, treatment, and complications. RESULTSThe incidence rate of hemorrhagic cystitis after radiation for prostate cancer was 11.1%. There was no significant difference between external beam and intensity-modulated radiation therapy and the development of hemorrhagic cystitis (P = .18). Patients developed hemorrhagic cystitis an average of 79.1 months (4-230 months) after radiation. The average number of admissions was 2.5 (1-9) with an average length of stay of 7.6 days (1-42 days). Fifty-two percent of patients required blood transfusion with an average of 4.3 units transfused per patient (1-33U). The most common treatment was cystoscopy with fulguration/clot evacuation in 86% of patients. Complications included urinary tract infection, acute kidney injury, urosepsis, and even death. CONCLUSIONThe incidence of hemorrhagic cystitis following radiation therapy for prostate cancer is under-reported in the literature. Hemorrhagic cystitis is associated with high morbidity and complications for patients, requiring multiple hospitalizations, blood transfusions, and procedures. Advances in radiation have not significantly reduced the risk of developing hemorrhagic cystitis.

Potential of hyperbaric oxygen in urological diseases.

Hyperbaric oxygen therapy is a promising medical technology that delivers oxygen to targeted tissues at high pressure to increase the amount of dissolved oxygen in the blood. Over the past three decades, hyperbaric oxygen has been used in a variety of conditions, including radiation-induced tissue injuries, non-healing states with ischemia and malignant neoplasms. In the field of urology, hyperbaric oxygen has also been applied to some pathological conditions (e.g. radiation-induced hemorrhagic cystitis, Fournier gangrene, interstitial cystitis, male infertility, acute kidney injury and urological cancers). In normal and injured tissues, hyperoxia from hyperbaric oxygen therapy contributes to anti-inflammation, angiogenesis through endothelial proliferation, enhanced fibroblastic activity, increased lymphocyte and macrophage activity, and bactericidal effects with the aim of wound repair. In cancerous tissues, the enhanced supply of oxygen into the hypoxic cancer cells can exert inhibitory effects on factors that contribute to their aggressiveness (e.g. cell survival, escape from apoptosis, epithelial-to-mesenchymal transition and tumor immunotolerance), and sensitize the tumor to radiation therapy and chemotherapy. However, further research, including multicenter clinical studies, is essential for determining the role of hyperbaric oxygen therapy in refractory urological diseases that are resistant to conventional therapies.

Endovascular management of radiation-induced hemorrhagic cystitis

Radiation-induced hemorrhagic cystitis (HC) is an unpleasant and sometimes life-threatening complication confronted while treating pelvic malignancies. A wide array of treatment modalities such as bladder irrigation, fulguration, hyperbaric oxygen therapy, and surgical methods has been proposed to treat hematuria, but there is no consensus on the optimal therapeutic strategy for the same. Reported here is a successful superselective embolization of the bilateral vesical arteries in a patient with refractory radiation-induced HC. This technique proved to be effective in controlling intractable hemorrhage and can be considered an option for the treatment of HC not amenable to conventional techniques.

Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis.

Methodology A comprehensive review of studies examining radiation-induced hemorrhagic cystitis was performed using PubMed, Medline, and the Cochrane Library database. The bibliographies of relevant articles were searched to avoid exclusion of meaningful articles. Where available, focus was given to systematic reviews and comparative studies; however, due to a lack of high-quality evidence, case series were included and made up the majority of articles included. All articles were reviewed using the evidence-based medicine levels, with a modified Oxford grading system for recommendations.

A contemporary review about the management of radiation-induced hemorrhagic cystitis.

There are various specific therapeutic intervention available to treat hemorrhagic cystitis, once emergency treatment has been carried out. The lack of prospective studies, because of the relative rarity of this condition, makes it difficult to hierarchize the therapeutic sequence. The present review presents and summarizes the literature published on radiation-induced hemorrhagic cystitis from April 2015, date of a precedent exhaustive review, to March 2018. During our period of interest, 13 clinical studies and two new clinical trials protocols were published. Most of the clinical studies were retrospective and presented data about hyperbaric oxygen (HBO) therapy, comforting its place as a well tolerated and effective first-line treatment. Other studies reported the outcomes of treatments with alum, formalin, silver nitrate, fulguration with laser or definitive surgery. Although authors seem to agree that formalin and surgery have their role as effective but potentially morbid last-line treatments, there is no consensus on primary approach to management of radiation-induced hemorrhagic cystitis beyond symptomatic measures. Several treatments have proven excellent response rates and few side effects. The results of on-going prospective studies on mesenchymal stromal cells or tacrolimus instillations are awaited, but the main discriminating factor to choose between treatments remains local availability.

Cancer survivorship issues with radiation and hemorrhagic cystitis in gynecological malignancies.

Given that more cancers are being diagnosed earlier and that treatment of cancer is improving, health issues of cancer survivors are becoming more common and apparent. Pelvic radiation therapy for the treatment of gynecological cancers can lead to long-term collateral damage to the bladder, a condition termed radiation cystitis (RC). Late sequelae may take many years to develop and include incontinence and pain as well as hematuria. RC is a rare but potentially life-threatening condition for which there are few management and treatment options. There are limited data in the literature regarding the effects of radiation on the bladder after gynecological cancer therapy and we hereby review the literature on cancer survivorship issues of pelvic radiation for gynecology literature. Treatment options are available for patients with radiation-induced hemorrhagic cystitis. However, most treatments are risky or only effective for a short timeframe and no therapy is currently available to reverse the disease progress. Furthermore, no standardized guidelines exist describing preferred management options. Common therapies include hyperbaric oxygen therapy, clot evacuation, fulguration, intravesical instillation of astringent agents, and surgery. Novel developing strategies include Botulinum Toxin injections and liposomal-tacrolimus instillations. These treatments and strategies are discussed. In this review, we will present current and advanced therapeutic strategies for RC to help cancer survivors deal with long-term bladder health issues.

Superselective Embolization of Bilateral Inferior Vesical Arteries for the Management of Radiation-Induced Hemorrhagic Cystitis Refractory to Conventional Methods

: Hemorrhagic cystitis (HC) following radiation therapy of pelvic malignancy is a serious and sometimes life-threatening complication. Various methods including bladder irrigation, fulguration, intravesical instillation, oral or systemic agents, hyperbaric oxygen therapy and surgical methods have been proposed to control hematuria. However, there is no consensus on the optimal therapeutic strategy for radiation-induced HC. We recently performed superselective embolization of the bilateral inferior vesical arteries in a patient with radiation-induced HC refractory to conventional treatment methods. This technique is effective for achieving the control of refractory hemorrhage and can be considered an option for the treatment of radiation-induced HC.

Scoping Review and Meta-analysis of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis.

To critically review and summarize existing literature assessing the effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of radiation-induced urologic injury. Though 5 of the included 13 studies were published in the last 2-3years, the only randomized controlled study was performed in 2012. Recent studies have confirmed the safety and efficacy of HBOT as well as identified risk factors for success vs. failure of HBOT for hemorrhagic radiation cystitis (HRC). Of the 602 patients that received HBOT for HRC, 84% had a partial or complete resolution. In the 7 studies that utilized RTOG/EORTC, 75% of patients saw an improvement in hematuria of at least one grade (out of possible 5 total). Of the 499 patients with documented follow-up, 14% experienced recurrence, with a median time to recurrence of 10months (6 to 16.5months).

Evaluation of Hyperbaric Oxygen Therapy in the Treatment of Radiation-induced Hemorrhagic Cystitis

To evaluate the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of postradiation hematuria (PRH) and to identify the predictive factors for a successful outcome. We conducted a retrospective study and included all patients with PRH treated with HBO in a university hospital center between January 2003 and December 2013. We studied the patients' clinical characteristics, radiotherapy indication, treatments preceding HBO, the grade of hematuria diagnosed based on the Common Terminology Criteria for Adverse Events classification v 4.03 and the efficacy of HBO. The success of HBO was defined as the total or partial resolution of hematuria. We included 71 patients with a median age of 72 (39-87) years. PRHs were severe (grade ≥3) in 50 (70.4%) of the cases. Radiotherapy was indicated in the treatment of prostate cancer in 61 (85.9%) patients. The median length of time between hematuria and HBO was 8 (1-154) months. Prior to HBO, 46 (64.8%) patients underwent electrocoagulation of the bladder. HBO sessions were compounded by 9 cases of barotraumatic otitis, 5 cases of transient visual disturbance, and 1 case of finger paresthesia. On average, 29 (3-50) sessions were carried out. Treatment was effective in 46 (64.8%) patients, 37 (52.1%) of whom were completely cured. A hematuria grade of less than 3 was a predictive factor in the successful treatment (P = .027). Median follow-up was 15 (1-132) months. HBO completely resolves PRH in 52.1% of cases. Prolonged patient follow-up is required to confirm the efficacy of this treatment.

Challenges and Opportunities in Radiation-induced Hemorrhagic Cystitis.

As diagnosis and treatment of cancer is improving, medical and social issues related to cancer survivorship are becoming more prevalent. Hemorrhagic cystitis (HC), a rare but serious disease that may affect patients after pelvic radiation or systemic chemotherapy, has significant unmet medical needs. Although no definitive treatment is currently available, various interventions are employed for HC. Effects of nonsurgical treatments for HC are of modest success and studies aiming to control radiation-induced bladder symptoms are lacking. In this review, we present current and advanced therapeutic strategies for HC to help cancer survivors deal with long-term urologic health issues.

Treatment of long-term radiation injuries in the urinary tract

Radiotherapy plays a substantial role in the treatment of malignancies. The side effects and long-term sequelae of radiotherapy are manifold and depend on the single doses and the total dosage, the time interval between two doses, the size of the irradiated tissue area and the radiation sensitivity of individual tissues. The urological complications following radiotherapy include inflammatory alterations of the bladder (radiation-induced hemorrhagic cystitis), fibrosis with subsequent radiogenic shrunken bladder, stenosis of the ureter and formation of secondary retroperitoneal fibrosis. In addition, the formation of necrosis can result in rectourethral, uterovaginal and vesicovaginal fistulas up to formation of a cloaca. The main problem following radiotherapy is microangiopathy in the irradiated area. The therapy of radiation injuries in the urogenital tract depends on the extent and localization of the radiation damage. In particularly severe cases extremely complex reconstructive techniques are necessary for restoration of functionality of the urinary tract and preservation of renal function. Radiation injuries can remain asymptomatic for a long time so that a closely controlled urological surveillance is indispensable. The correct selection of the intestinal segments for surgical removal of radiation injuries in the urogenital tract is of pivotal importance.

Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management.

Cystitis and proctitis are defined as inflammation of bladder and rectum respectively. Haemorrhagic cystitis is the most severe clinical manifestation of radiation and chemical cystitis. Radiation proctitis and cystitis are major complications following radiotherapy. Prevention of radiation-induced haemorrhagic cystitis has been investigated using various oral agents with minimal benefit. Bladder irrigation remains the most frequently adopted modality followed by intra-vesical instillation of alum or formalin. In intractable cases, surgical intervention is required in the form of diversion ureterostomy or cystectomy. Proctitis is more common in even low dose ranges but is self-limiting and improves on treatment interruption. However, treatment of radiation proctitis is broadly non-invasive or invasive. Non-invasive treatment consists of non-steroid anti-inflammatory drugs (NSAIDs), anti-oxidants, sucralfate, short chain fatty acids and hyperbaric oxygen. Invasive treatment consists of ablative procedures like formalin application, endoscopic YAG laser coagulation or argon plasma coagulation and surgery as a last resort.

A Practical Approach to the Management of Radiation-Induced Hemorrhagic Cystitis.

Radiation-induced hemorrhagic cystitis (HC) is a complication of pelvic radiotherapy, mainly for prostate and uterine cancers. In the acute phase, patients feel urinary urgency and bladder pain. This phase is reversible after radiotherapy. In the chronic stage, an irritative syndrome is coupled with hematuria during the 2-10 years following radiotherapy. Cystoscopy shows white and frosted mucosa with telangiectasia. The incidence is estimated at 5 % or less. It is suggested that the radiation oncologist reviews the dosimetry plan to validate that the lesions coincide with significant radiation exposure confirming diagnosis of radiation-induced HC. The treatment for HC is first symptomatic, with bladder lavage, clot evacuation, coagulation via cystoscopy and blood transfusions if necessary. Subsequently, hyaluronic acid bladder instillation can be done with little toxicity. Hyperbaric oxygen therapy delivers pure oxygen to patients in a pressurized cabin, promoting angio-neogenesis and lowering hypoxia to the irradiated tissues. The clinical response rate is estimated to be around 80 %. Nevertheless, this approach is limited by the low availability, and length of treatment. While surgery remains an effective treatment for HC, it is the last option because of the high morbidity and mortality risks. Prospective studies need to be conducted to identify and evaluate new interventions, particularly for HC.

Hyperbaric oxygen therapy for refractory radiation-induced hemorrhagic cystitis.

To analyze the efficacy of hyperbaric oxygen for the treatment of radiation-induced hemorrhagic cystitis and to identify factors associated with successful treatment. Clinical records from 176 patients with refractory radiation-induced hemorrhagic cystitis treated at the Portuguese Navy Center for Underwater and Hyperbaric Medicine, during a 15-year period, were retrospectively analyzed. Evolution of macroscopic hematuria was used to analyze treatment efficacy and correlated with other external variables. From a total of 176 treated patients, 23.9% evidenced other radiation-induced soft tissue lesions. After an average on 37 sessions, 89.8% of patients showed resolution of hematuria, with only 1.7% of adverse events. In our sample, hematuria resolution after treatment with hyperbaric oxygen was statistically associated to the need for transfusion therapy (P=0.026) and the number of sessions of hyperbaric oxygen (P=0.042). No relationship was found with the remaining variables. Refractory radiation-induced hemorrhagic cystitis can be successfully and safely treated with hyperbaric oxygen. Treatment effectiveness seems to be correlated with the need for transfusion therapy and the number of sessions performed.

Radiation-induced hemorrhagic cystitis.

To better understand the mechanism of radiation-induced hemorrhagic cystitis and the advantages and disadvantages of available treatment options for bladder hemorrhage as well as preventive measures. There have been several attempts recently to manage hemorrhagic cystitis with hyperbaric oxygen therapy, transurethral coagulation using Greenlight potassium-titanyl-phosphate laser and other different treatment modalities, but we still need more investigation on larger cohort studies. Hemorrhagic cystitis is an uncommon urological problem. It is most often caused by radiation therapy and cyclophosphamide, but can be associated with other contributing factors. Technological advances in radiation therapy have resulted in greater treatment efficacy, with significant reduction in side-effects such as hemorrhagic cystitis. Higher dose radiation treatment, however, is more often associated with problematic hemorrhagic cystitis. Treatment of hemorrhagic cystitis is multifactorial and can range from simple bladder irrigation to cystectomy with urinary diversion.

Mucosa-sparing, KTP Laser Coagulation of Submucosal Telangiectatic Vessels in Patients With Radiation-induced Cystitis: A Novel Approach

This study aimed evaluate the safety and feasibility of endoscopic potassium titanyl phosphate (KTP) laser application in the management of patients with radiation-induced hemorrhagic cystitis (RHC). We retrospectively reviewed the records of 20 patients with RHC who underwent endoscopic KTP laser ablation of telangiectatic bladder vessels between October 2005 and January 2013. After initial cystoscopy, KTP laser was used to ablate the submucosal vasculature while preserving the overlying mucosa. The surgical outcome was evaluated by duration of hematuria-free interval, number of episodes of hematuria, and number of required medical and/or surgical interventions after initial treatment. Overall, 20 patients underwent 26 sessions of KTP laser ablation of bladder vessels. The procedure was able to stop bleeding 92% of the time and the average hematuria-free interval after ablation was 11.8 months, with a range of 1-37 months. In 13 patients (65%) hematuria resolved after 1 session of KTP laser treatment, whereas 5 patients (25%) required multiple sessions. Two patients (10%) with severe hematuria continued to have bleeding after laser treatment, which necessitated proximal diversion of urine with percutaneous nephrostomy tubes to control bleeding. This study suggests that KTP laser, with its unique photoselectivity property, is a safe, effective, and durable treatment with minimal side effects for ablation of submucosal bladder vessels in patients with RHC.