What are the guideline sources, guidelines and references for Radiation-induced hemorrhagic cystitis ?
Guideline sources The following summarized guidelines for the evaluation and management of radiation-induced hemorrhagic cystitis (RHC) are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2019) and the Journal of Clinical Urology (JCU 2014). 1 2 Calculator Calculator EORTC/RTOG classification of ra Grading of hemorrhagic cystitis Guidelines 1. Screening and diagnosis Differential diagnosis: assess patients with post-radiation hematuria to identify or exclude other pathological factors that may explain or contribute to the patient's symptoms. B https://web.pathway.md/diseases/recgLo6heZQ7e9GWv 1/4 6/24/23, 2:57 PM Radiation-induced hemorrhagic cystitis Pathway Diagnosis: diagnose hemorrhagic cystitis based on symptoms and exclusion of other conditions, such as bladder neoplasms, bacterial or fungal UTIs. E 2. Diagnostic investigations Initial assessment: elicit careful history, perform physical examination and obtain laboratory examination as the basic assessment. E Diagnostic imaging: Obtain CT to exclude bleeding from the upper urinary tract. E Consider obtaining MRI in patients with a past history of non-urological pelvic malignancy. E 3. Diagnostic procedures Cystoscopy: perform at least one initial cystoscopy with or without fulguration of suspect lesions and biopsy of any lesion concerning for malignancy for diagnostic and therapeutic purposes in all patients with post-radiation hematuria. B 4. Respiratory support Hyperbaric oxygen therapy: As per CUA 2019 guidelines, consider offering hyperbaric oxygen therapy for early management of patients with RHC failed cystoscopy and fulguration. Recognize that significant resource and expertise requirements may limit its use. C As per JCU 2014 guidelines, consider offering hyperbaric oxygen therapy in patients with hemorrhagic cystitis. E 5. Medical management General principles: Ensure a multimodality stepwise approach for the treatment of patients with hemorrhagic cystitis. E Decide on choice of therapy depending on the degree of hematuria. E Supportive therapy: consider offering conservative methods including bladder irrigation, rehydration and promotion of diuresis in patients with grade I-III hemorrhagic cystitis. E Sodium pentosan polysulfate: consider offering sodium pentosan polysulfate to reduce hematuria in patients with RHC. Recognize that it is safe and generally well-tolerated, however, the slow onset of action may limit its usefulness in the treatment of patients with acute or severe RHC. C https://web.pathway.md/diseases/recgLo6heZQ7e9GWv 2/4 6/24/23, 2:57 PM Radiation-induced hemorrhagic cystitis Pathway Tranexamic acid: consider administering oral tranexamic acid 1 g TID in patients with hemorrhage or at risk of hemorrhage. E Other systemic agents: insufficient evidence to support the use of different other systemic agents for the treatment of patients with RHC. I Management of severe hemorrhagic cystitis: Offer more aggressive treatment including cystoscopic clot evacuation and continuous irrigation in patients with grade IV hemorrhagic cystitis. E Consider offering further treatment in patients with severe hemorrhagic cystitis - hemorrhage refractory to irrigation and intravesical instillation - depending on whether the bladder disease is focal or diffuse. E 6. Therapeutic procedures Alum irrigation: consider performing bladder irrigation with alum in patients with RHC. Recognize that it is a practical, easily applied and generally well-tolerated procedure with a comparatively acute onset of action. Use special caution in patients with poor renal function. C Intravesical hyaluronic acid: As per CUA 2019 guidelines, consider administering intravesical hyaluronic acid to improve symptoms of RHC and provide further benefit for LUTS in patients with RHC. Recognize that its slow onset of action and lack of research in severe hematuria may limit its usefulness in the acute and inpatient settings. C As per JCU 2014 guidelines, consider administering intravesical sodium hyaluronate in patients with hemorrhagic cystitis failed conservative measures. E Intravesical formalin: perform intravesical formalin instillation only in patients failed less invasive treatments, because of the significant morbidity associated with the procedure. Attempt to prevent reflux into the upper tracts and carefully monitor patients for potential side effects, if the treatment is used. B Other intravesical agents: insufficient evidence to support the use of different other intravesical agents in patients with RHC. I Clot removal: remove clots from the bladder before initiating any treatment. E Endoscopic hemostasis: insufficient evidence to support the use of hemostatic agents during endoscopy for early management of patients with RHC. I Laser therapy: insufficient evidence to support the use of endoscopic laser therapy for early management of patients with RHC. I Transarterial embolization: As per CUA 2019 guidelines, consider performing transarterial embolization to control RHC, if less invasive methods have been unsuccessful. Prefer selective or super-selective embolization when available to lessen possible side effects. C https://web.pathway.md/diseases/recgLo6heZQ7e9GWv 3/4 6/24/23, 2:57 PM Radiation-induced hemorrhagic cystitis Pathway As per JCU 2014 guidelines, consider performing selective embolization in extreme cases when all other treatment options have failed. E 7. Surgical interventions Cystectomy and urinary diversion: As per CUA 2019 guidelines, perform urinary diversion with or without cystectomy only in patients with RHC failed previously available therapy. Recognize and inform patients about the high morbidity and mortality of the procedure before proceeding with surgery. B As per JCU 2014 guidelines, perform surgery as an option of last resort in patients with symptoms unresponsive to primary forms of treatment. E 8. Preventative measures Prophylaxis: consider administering sodium hyaluronate 40 mg/50 ml in patients at increased risk of hemorrhagic cystitis, such as patients receiving external beam radiation therapy and brachytherapy for cervical or endometrial cancer. E Show 3 more References 1. George Goucher, MD, Fred Saad et al. Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J. 2019 Feb; 13 2 15 23. Open 2. A Thompson, A Adamson, A Bahl et al. Guidelines for the diagnosis, prevention and management of chemical- and radiation-induced cystitis. J Clin Urol. 2014 Jan;7 1 25 35. Open 3. Jessica H Hannick, Martin A Koyle. Canadian Urological Association Best Practice Report: Pediatric hemorrhagic cystitis. Can Urol Assoc J. 2019 Nov;13 11 E325 E334. Open https://web.pathway.md/diseases/recgLo6heZQ7e9GWv 4/4