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Practical Management of Post- Irradiation Haemorrhagic Cystitis JHL Tsu Division of Urology Pamela Youde Nethersole Eastern Hospital.

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Presentation on theme: "Practical Management of Post- Irradiation Haemorrhagic Cystitis JHL Tsu Division of Urology Pamela Youde Nethersole Eastern Hospital."— Presentation transcript:

1 Practical Management of Post- Irradiation Haemorrhagic Cystitis JHL Tsu Division of Urology Pamela Youde Nethersole Eastern Hospital

2 JHSGR Sept 2006 Background Haemorrhagic cystitis  Acute or insidious onset diffuse bladder inflammation with haemorrhage Aetiologies  Radiation  Chemical eg. cyclophosphamide  Viral infection  Secondary bladder amyloidosis

3 JHSGR Sept 2006 Incidence No uniformly quoted incidence in literature  7-9% of patients with pelvic irradiation Overall incidence G3-4 bladder toxicity  RT to Ca prostate2-9%  RT to Ca cervix2-5%  RT to Ca bladder2-12% Ram Proc R Soc Med 1970

4 JHSGR Sept 2006 Radiotherapy Used in primary, adjuvant or palliative setting for various pelvic malignancies Urinary bladder is irradiated  Intentionally eg. Ca bladder  Incidentally eg. Ca prostate, Ca cervix

5 JHSGR Sept 2006 Radiation induced endothelial damage Subendothelial intimal proliferation Endarteritis obliterans Ischaemia to mucosa and detrusor Focal / diffuse ischaemic necrosis Progressive fibroblast proliferation in submucosa & detrusor Chronically hypoxic mucosa Contracted bladder with poor compliance Haematuria Ulceration & poor healing

6 JHSGR Sept 2006 General Measures General  Resuscitation  Transfusion  Evacuation of clots Manual (bedside) Endoscopic (operating theatre) Continuous NS bladder irrigation afterwards Often not enough to achieve haemostasis Silver cannula Toomey

7 JHSGR Sept Electrocautery 2. Intravesical therapy 3. Systemic therapy 4. Embolization 5. Surgery Specific Treatment Options

8 JHSGR Sept Electrocautery 2. Intravesical therapy 3. Systemic therapy 4. Embolization 5. Surgery Specific Treatment Options

9 JHSGR Sept 2006 Electrocautery Achieves haemostasis cystoscopically First line of treatment Pros  Can be done right after cystoscopic clot evacuation Cons  Often not possible due to diffuse bleeding

10 JHSGR Sept Electrocautery 2. Intravesical therapy 3. Systemic therapy 4. Embolization 5. Surgery Specific Treatment Options

11 JHSGR Sept Intravesical therapy Specific Treatment Options  Hydrodistension (Helmstein balloon)  Silver nitrate  Alum  Formalin  Phenol  Prostaglandins  Epsilon Amino Caproic Acid (EACA)

12 JHSGR Sept 2006 Intravesical Silver Nitrate Silver Nitrate  Organic salt that coagulates protein on contact, achieving haemostasis Efficacy : 68-70% Toxicity  Bilateral obstructive uropathy  (Crystallisation of AgNO 3 salt inside ureters) Jenkins J Urol 1986 Vijan J Urol 1988 Raghavaiah J Urol 1977

13 JHSGR Sept 2006 Intravesical Silver Nitrate Pros  Well tolerated  Local anaesthesia procedure at bedside Cons  Temporary haemostasis  May need repeated instillations

14 JHSGR Sept 2006 Intravesical Alum Alum  Aluminium potassium sulfate  Industrial chemical to purify water Reported efficacy :67-100% Mechanism  Precipitates protein over bleeding vessels, causing vasoconstriction and haemostasis Kennedy BJU 1986 Arrizabalaga BJU 1987 Goel J Urol 1985

15 JHSGR Sept 2006 Intravesical Alum Pros  Relatively well tolerated  Can be instillated under local anaesthesia Toxicity  Aluminium toxicity Manifested as obtundation, encephalopathy, seizure Systemic absorption in patients with renal impairment 2 deaths attributed to this Kavoussi J Urol 1986 Modi Am J Kidney Dis 1988 Seear Urology 1990

16 JHSGR Sept 2006 Intravesical Formalin Formalin  Industrial chemical as tissue fixative and embalming agent Efficacy : 80-92% complete haemostasis Intravesical Formalin  Cross-links proteins and precipitates it over mucosal surfaces, sealing off bleeding vessels Brown Med J Aust 1969 Kumar J Urol 1975 Shah J Urol 1973

17 JHSGR Sept 2006 Intravesical Formalin Toxicity  75% major complications using 10% solution  Minimal complications but similar efficacy using lower concentrations (1-2%)  Minor : fever, dysuria  Major : contracted bladder, vesico-ureteral reflux, ureteric stricture, vesico-vaginal fistula Fair Urology 1974 Donahue J Urol 1989 Donohue J Urol 1989

18 JHSGR Sept 2006 Intravesical Formalin Pros  Most studied intravesical agent  Time-tested method of haemostasis Cons  Requires anaesthesia  Potentially severe complications Mostly with 10% solution

19 JHSGR Sept Electrocautery 2. Intravesical therapy 3. Systemic therapy 4. Embolization 5. Surgery Specific Treatment Options  iv Pentosanpolysulphate  iv / oral Epsilon Amino Caproic Acid (EACA)  iv Vasopressin  Hyperbaric Oxygen (HBO)

20 JHSGR Sept 2006 Hyperbaric Oxygen Delivery of 100% oxygen at hyperbaric condition (> 1 atm.) Mechanism  Hyperbaria increases plasma O 2 concentration  Promotes angiogenesis, neovascularization and granulation into hypoxic tissue  Efficacy : % complete response Feldmeier Undersea Hyperb Med 2002 Corman J Urol 2003, Bevers Lancet 1995

21 JHSGR Sept 2006 Hyperbaric Oxygen Pros  Alters pathophysiology of the disease  No anaesthesia required Cons  Limited access  Not suitable for critical patients  Often prolonged treatment required

22 JHSGR Sept Electrocautery 2. Intravesical therapy 3. Systemic therapy 4. Embolization 5. Surgery Specific Treatment Options

23 JHSGR Sept 2006 Embolization Internal iliac artery embolization  Efficacy : 90-92% Pros  Local anaesthesia procedure Cons  Requires IR expertise  Haematuria recurs when collateral develops  Ischaemia and necrosis of pelvic organs, gluteus McIvor Clin Radiol 1982

24 JHSGR Sept 2006 Surgery Surgical options  Urinary diversion Bilateral nephrostomies Cutaneous ureterostomy Ileal conduit Efficacy : 87.5% durable response  Salvage cystectomy Pomer BJU 1983

25 JHSGR Sept 2006 Surgery Pros  Last resort when all else fails Cons  May not be feasible as patient too ill already  Significant complication rates  High perioperative mortality rate

26 AgentMechanismProsConsCx ElectrocauteryElectric CauteryAvailable Anaesthesia, May not work Bladder perforation AgNO 3 Chemical CauteryBedside, LABleeding recurs Obstructive uropathy AlumChemical CauteryBedside, LA Contraindicated in uraemia Aluminium toxicity, Death Formalin Chemical Cautery, fixative effect EffectiveAnaesthesia Bladder contracture…etc, Death HBONeovascularizationChamber, NANot available Barotrauma, claustrophobia EmbolizationIschaemiaXR suite, LA Radiology expertise Bladder necrosis Surgery Urinary diversion Cystectomy Last resortAnaesthesiaDeath

27 JHSGR Sept 2006 To bring home Post-irradiation haemorrhagic cystitis….  A particularly difficult clinical problem of haemostasis for urologist  …. the practical management of which involves…..

28 JHSGR Sept 2006 Electrocautery Intravesical therapy Hyperbaric Oxygen Embolization Surgery Usually fails Haemostasis may not last Works but beware of Cx Not always available Possible if radiologist around Last resort General measures

29 JHSGR Sept 2006 Thank you


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