CUA BPR radiation induced hemorrhagic cystitis 2019

Question 1

What are grade 1,2,3 radiation induced hemorrhagic cystitis? (EORTC/RTOG)

Answer 1

Grade 1: slight epithelial atrophy, minor telengactasia, MICROSCOPIC HEMATURIA
Grade 2: moderate frequency, generalized telengactasia, intermittent macroscopic hematuria
Grade 3: Severe frequency, dysuria, generalized telengactasia, frequent macroscopic hematuria and decreased bladder capacity

Question 2

What are Grade 4 and 5?

Answer 2

Grade 4: necrosis/contracted bladder, severe hemorrhagic cystitis
Grade 5: death directly related to hemorrhagic cystitis

Question 3

What does RHC look like on cystoscopy?

Answer 3

Diffuse erythema, telangiectasia with or without ulcerations.

Question 4

Should all patients with RHC have cysto?

Answer 4

of course, it is hematuria, +/- offer fulguration as well. Bx any suspect lesions for malignancy.

Question 5

What are intravesical agents for management of RHC?

Answer 5

alum irrigation, Hyaluronic acid, formalin

Question 6

how is alum given?

Answer 6

Clear out the bladder, 1% alum solution, irrigated at 250-300ml per hour

Question 7

What are side effects of alum irrigation?

Answer 7

bladder spasms, SP discomfort, clotting of the catheter due to precipitant, risk of aluminum toxicity in those with renal failure

Question 8

Is hyaluronic acid as effective as HBOT?

Answer 8

yes, per an RCT they quote in the GL

Question 9

What does the GL say regarding hyaluronic acid?

Answer 9

HA may improve hematuria (G 1-3) and help with LUTS, delayed onset of action and lack of research in (G>3) brings its utility into question in acute setting.

Question 10

what are systemic options for management of RHC?

Answer 10

HBOT and sodium pentosan polysulfate

Question 11

Described how HBOT is given?

Answer 11

100% O2 at 1.4-3ATM, this well help rapid neovascularization, vasoconstriction and formation of healthy granulation tissue. This has been reported for upto 30 days.

Question 12

What are complications of HBOT?

Answer 12

barotrauma, barotraumatic otitis, visual disturbances

Question 13

Can you go straight to HBOT after cysto fulg?

Answer 13

yes of course, it also works for G4 and seems to have a durable response.

Question 14

How is sodium pentosan polysulfate administered?

Answer 14

Orally, it is a semisynthetic polysacharide

Question 15

what is the onset of action of sodium pentosan polysulfate?

Answer 15

1-8 weeks

Question 16

What is a side effect of SPP?

Answer 16

pigmentary maculopathy

Question 17

What are side effects of trans arterial embolization?

Answer 17

bladder necrosis, brow sequard syndrome, buttock claudication,
SELECTIVE OR SUPERSELECTIVE EMBOLIZATION will reduce side effects

Question 18

How is formaling administered?

Answer 18

In Or with spinal or GA, (1,2,4 upto 10%), do on table cystogram if not already done, protect patient and yourself, (use fulgretty catheters if there is reflux), clear out bladder, control obvious bleeders with fulg, run in your formalin. ( keep for 10-15 min). then run CBI

Question 19

What are side effects of formalin?

Answer 19

ureteric stricture, upjo, uvjo, decreased bladder capacity, vesicular fistulas, mortality( none reported with (1-2%). the higher the concentration of formalin used the higher the risk of complications

Question 20

What if you got someone with RHC and nothing works including formalin?

Answer 20

Urinary diversion with or without cystectomy.
NTs may be a good option in a patient who is not a good surgical candidate or in general as preoperative complications are high.