Supratrigonal systectomy: last line treatment for radiation-induced hemorrhagic cystitis

Hemorrhagic cystitis is defined by the presence of hematuria, lower urinary tract symptoms and cystoscopy findings indicative of underlying urothelial damage. It is common in patients with prior radiotherapy for pelvic malignancies. The severity of the bleeding can vary from mild to severe hematuria refractory to conservative therapy and with a continuous need for transfusions. Treatment can be challenging not only by the lack of clear guidelines but also the multiple comorbidities of these patients. Urinary diversion with or without cystectomy should be reserved for those who have failed all the previously available therapy, because of the morbidity/mortality associated with this type of procedure. Supratrigonal cystectomy can be an option in patients with intense fibrosis of the pelvic region. The purpose of this article is to present the results of our institution with supratrigonal cystectomy with urinary diversion as a last line treatment for radiation-induced hemorrhagic cystitis.

We retrospectively analyzed 17 patients who underwent supratrigonal cystectomy and bladder mucosa fulguration with urinary diversion for refractory radiation-induced hemorrhagic cystitis in our institution from January 2010 to December 2020.

Median patient age at time of cystectomy was 69 years and 64.7% (11) were females. The most common etiology was prior radiation therapy for gynecologic malignancies (11-64.7%). All the patients had prior therapy with bladder irrigation and fulguration. Besides that, 29.4% (n=5) received intravesical therapy with formalin, 11.8% (n=2) hyperbaric oxygen therapy and 5.9% (n=1) prior urinary diversion. Median time between radiation therapy and cystectomy was 65 months. Median ASA score of 3, median preoperative hemoglobin was 9,6mg/dl and 10.5 mg/dl at time of discharge after surgery. Ileal conduit was used in 52.9% (9), cutaneous ureterostomy in 41.2% (7) and ureterosigmoidostomy in 5.9% (1). Majority of patients (10-58.8%) did not require any blood transfusion during surgery or during their stay. Clavien-Dindo complications grade III or higher occurred in 29,4% (5). Median hospital stay postoperative was 12 days. No mortality was reported in the 30 days after surgery. Median follow-up after cystectomy was 28 months, with a 1-year survival of 93.3% (14 of 15) and 3-year survival of 83.3% (10 of 13). There was no difference in the presence of postoperative complications or overall survival between the types of urinary diversion.

This represents one of the largest series on cystectomy in hemorrhagic cystitis, that we found to this date. Supratrigonal cystectomy is a valid option as a last line treatment for radiation-induced hemorrhagic cystitis, reducing the risks associated with simple cystectomy in patients with prior pelvic radiation.