Hemorrhagic cystitis after hematopoietic stem cell transplantation: A challenge for the pediatric urologist

Hemorrhagic cystitis (HC) is a serious event that can occur after hematopoietic stem cell transplantation (HSCT). Treatment goals are primarily to preserve life, and then the functionality of the bladder. There is no standard therapeutic approach for HC. Described treatment options provide low success rates and are related to potential life-threatening side effects. The aim of this study was to describe our experience in treatment of HC following HSCT.

This was a retrospective study of patients with HC treated at our institution between January 2010 and October 2016. We analyzed demographics, underlying diagnosis, and treatment modalities.

We treated 39 patients with HC. Mean age was 9.4 years (SD 4.20) and 64% were males. Acute leukemia was the most common underlying diagnosis in 27 (69%). Mean time from HSCT to HC onset was 55.46 days (SD 112.35). HC grades were: I (3), II (21), III (8), and IV (7). BK-viuria was present in 34 patients (87.2%). Non-invasive treatment was performed in 28 patients (71.8%). The remaining 11 (28.2%) required urological intervention (all high-grade), consisting of bladder irrigation in all of these. Additional treatments consisted of: intravesical cidofovir (4), intravesical sodium hyaluronate (5), cystoscopy and clot evacuation (4), selective angioembolization (2), percutaneous nephrostomy (1), and open extraction of bladder clots and cutaneous cystotomy (1). Overall, eight patients (20.5%) died as a result of the malignancy (3 in the urological intervention group), and of these four had active HC at death. Mean follow-up was 36.2 months (SD 24.9).

HC is associated with high morbidity and mortality. Treatment should be individualized and designed to prioritize survival. However, bladder function should be preserved for the future.