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.