Pereira José Alberto, Vieira-Brito Duarte, Lourenço Mário, Conceição Paulo, Godinho Ricardo, Peralta Pedro, Pereira Bruno Jorge, Rabaça Carlos
Urology Department, Portuguese Institute of Oncology, Coimbra.
Arch Ital Urol Androl. 2025 Jun 30;97(2):13492. doi: 10.4081/aiua.2025.13492. Epub 2025 May 26.
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.
出血性膀胱炎的定义为存在血尿、下尿路症状以及膀胱镜检查发现提示潜在的尿路上皮损伤。它在既往接受盆腔恶性肿瘤放疗的患者中很常见。出血的严重程度可从轻度血尿到保守治疗难以控制的严重血尿，且持续需要输血。治疗不仅因缺乏明确的指南而具有挑战性，还因这些患者存在多种合并症。对于那些所有先前可用治疗均失败的患者，应保留行或不行膀胱切除术的尿流改道，因为此类手术存在发病率/死亡率。对于盆腔区域有严重纤维化的患者，三角区上方膀胱切除术可能是一种选择。本文的目的是介绍我们机构采用三角区上方膀胱切除术并行尿流改道作为放射性出血性膀胱炎的最后一线治疗的结果。
我们回顾性分析了2010年1月至2020年12月在我们机构接受三角区上方膀胱切除术及膀胱黏膜电灼术并行尿流改道治疗难治性放射性出血性膀胱炎的17例患者。
膀胱切除术时患者的中位年龄为69岁，64.7%（11例）为女性。最常见的病因是既往接受妇科恶性肿瘤放疗（11例，占64.7%）。所有患者均曾接受膀胱冲洗和电灼治疗。除此之外，29.4%（n = 5）接受了膀胱内福尔马林治疗，11.8%（n = 2）接受了高压氧治疗，5.9%（n = 1）曾行尿流改道。放疗与膀胱切除术之间的中位时间为65个月。中位ASA评分为3分，术前中位血红蛋白为9.6mg/dl，术后出院时为10.5mg/dl。52.9%（9例）采用回肠膀胱术，41.2%（7例）采用皮肤输尿管造口术，5.9%（1例）采用输尿管乙状结肠吻合术。大多数患者（占58.8%，10例）在手术期间或住院期间无需输血。Clavien-Dindo并发症III级或更高等级发生在29.4%（5例）。术后中位住院时间为12天。术后30天内未报告死亡病例。膀胱切除术后的中位随访时间为28个月，1年生存率为93.3%（15例中的14例），3年生存率为83.3%（13例中的10例）。不同类型尿流改道在术后并发症的发生或总体生存方面无差异。
这是我们迄今发现的关于出血性膀胱炎膀胱切除术的最大系列研究之一。三角区上方膀胱切除术作为放射性出血性膀胱炎的最后一线治疗是一种有效的选择，可降低既往盆腔放疗患者单纯膀胱切除术相关的风险。
