Folgen der Strahlentherapie an der Harnblase: Therapieoptionen

Zusammenfassung

Hintergrund

Die strahleninduzierte Zystitis ist eine häufige Komplikation nach Strahlentherapien bei Beckenkarzinomen (z.B. Prostata, Blase, Zervix). Ihre Akuttoxizität beträgt bis zu 50%, Spättoxizität 5–11%. Zu den Auslösern zählen die Strahlendosis, Therapieplanung und patientenabhängige Faktoren wie Strahlensensibilität, Vorerkrankungen und Tabakkonsum. Die Erkrankung führt zu inflammatorischen und fibrotischen Veränderungen der Blasenschleimhaut, welche Symptome wie Dysurie und Hämaturie verursachen.

Methoden

Dieser Review gibt einen Überblick über die verfügbaren Therapieoptionen zur Behandlung der strahleninduzierten Zystitis. Dabei werden konservative, medikamentöse, interventionelle und chirurgische Ansätze beschrieben und hinsichtlich ihrer Effektivität, Sicherheit und Indikationen bewertet.

Ergebnisse

Bei der Akuttoxizität steht eine symptomorientierte konservativ-medikamentöse Behandlung im Vordergrund. Intravesikale Optionen wie Hyaluronsäure und Alaunlösung zeigen in Studien moderate Ansprechraten. Die hyperbare Oxygenierung erzielt mit 64–100% partieller Remission und geringen Nebenwirkungen vielversprechende Ergebnisse. Invasivere Optionen wie Embolisation und Zystektomie bleiben Ultima Ratio, da sie mit hohen perioperativen Risiken verbunden sind.

Schlussfolgerung

Die Therapie der strahleninduzierten Zystitis erfordert ein multimodales Vorgehen. Durch Standardisierung des Therapiealgorithmus können Wege gefunden werden, um Patientenergebnisse zu verbessern.

Abstract

Background

Radiation-induced cystitis is a common complication following radiotherapy for pelvic malignancies such as prostate, bladder, and cervical cancer. Acute toxicity occurs in up to 50% of patients, while late toxicity is observed in 5–11%. Triggering factors include radiation dose, treatment planning, and patient-related factors such as radiosensitivity, comorbidities, and smoking. The condition leads to inflammatory and fibrotic changes in the bladder mucosa, resulting in symptoms such as dysuria and haematuria.

Methods

This review provides a comprehensive overview of available therapeutic options for the management of radiation-induced cystitis. Conservative, pharmacological, interventional, and surgical approaches are described and assessed with respect to their efficacy, safety, and clinical indications.

Results

In cases of acute toxicity, treatment is primarily conservative and symptom-oriented. Intravesical therapies, such as hyaluronic acid and alum solution, demonstrate moderate response rates in clinical studies. Hyperbaric oxygen therapy has shown promising results, achieving partial remission in 64–100% of cases and demonstrating a favourable safety profile. More invasive interventions, including embolisation and cystectomy, are considered treatments of last resort due to their substantial perioperative risks.

Conclusion

The management of radiation-induced cystitis requires a multimodal treatment strategy. Standardisation of therapeutic algorithms may contribute to improved clinical outcomes and optimised patient care.

Schlüsselwörter

Strahlenzystitis - Hämaturie - Strahleninduzierte Zystitis - Intravesikale Spültherapien - Hyperbare Oxygenierung

Keywords

radiation cystitis - haematuria - radiation-induced cystitis

• Literatur

• 1 Smit SG, Heyns CF. Management of radiation cystitis. Nat Rev Urol 2010; 7: 206-214
• 2 Ma JL, Hennessey DB, Newell BP. et al. Radiotherapy-related complications presenting to a urology department: a more common problem than previously thought?. BJU Int 2018; 121 (Suppl. 3) 28-32
• 3 Mendenhall WM, Henderson RH, Costa JA. et al. Hemorrhagic radiation cystitis. American Journal of Clinical Oncology: Cancer Clinical Trials 2015; 38: 331-336
• 4 Sanguedolce F, Sancho Pardo G, Mercadé Sanchez A. et al. Radiation-induced haemorrhagic cystitis after prostate cancer radiotherapy: factors associated to hospitalization and treatment strategies. Prostate Int 2021; 9: 48-53
• 5 Kaplan JR, Wolf JS. Efficacy and Survival Associated With Cystoscopy and Clot Evacuation for Radiation or Cyclophosphamide Induced Hemorrhagic Cystitis. Journal of Urology 2009; 181: 641-646
• 6 Payne H, Adamson A, Bahl A. et al. Chemical- and radiation-induced haemorrhagic cystitis: Current treatments and challenges. BJU Int 2013; 112: 885-897
• 7 Pascoe C, Duncan C, Lamb BW. et al. Current management of radiation cystitis: a review and practical guide to clinical management. BJU Int 2019; 123: 585-594
• 8 Nuhn P, Thüroff J. Radiation-induced hemorrhagic cystitis – possible treatment options!. Urologie 2022; 61: 614-621
• 9 Inokuchi H, Mizowaki T, Norihisa Y. et al. Correlation between urinary dose and delayed radiation cystitis after 78 Gy intensity-modulated radiotherapy for high-risk prostate cancer: A 10-year follow-up study of genitourinary toxicity in clinical practice. Clin Transl Radiat Oncol 2017; 6: 31
• 10 Zwaans BMM, Nicolai HG, Chancellor MB. et al. Challenges and Opportunities in Radiation-induced Hemorrhagic Cystitis. Rev Urol 2016; 18: 57
• 11 Alesawi AM, El-Hakim A, Zorn KC. et al. Radiation-induced hemorrhagic cystitis. Curr Opin Support Palliat Care 2014; 8: 235-240
• 12 Cox JD, Stetz JA, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 1995; 31: 1341-1346
• 13 Chorbińska J, Krajewski W, Zdrojowy R. Urological complications after radiation therapy-nothing ventured, nothing gained: a Narrative Review. Transl Cancer Res 2021; 10: 1096-1118
• 14 Vanneste BGL, Van Limbergen EJ, Marcelissen TA. et al. Development of a Management Algorithm for Acute and Chronic Radiation Urethritis and Cystitis. Urol Int 2022; 106: 63-74
• 15 Pascoe C, Duncan C, Lamb BW. et al. Current management of radiation cystitis: a review and practical guide to clinical management. BJU Int 2019; 123: 585-594
• 16 Neckonoff E, Anderson CB. Advancements in Understanding and Managing Radiation Cystitis: A Comprehensive Review. Curr Urol Rep 2025; 26: 1-11
• 17 Sammour T, Kahokehr AA. Pelvic Radiation Disease. Clin Colon Rectal Surg 2022; 35: 204-211
• 18 D’Amico MJ, Foss H, Uhr A. et al. Hemorrhagic cystitis: a review of the literature and treatment options. Can J Urol 2022; 29: 11276-11283
• 19 Dołowy Ł, Krajewski W, Dembowski J. et al. The role of lasers in modern urology. Cent European J Urol 2015; 68: 175-182
• 20 Yang T-K, Wang Y-J, Li H-J. et al. Efficacy and Safety of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13: 4724
• 21 Weiss JP, Boland FP, Mori H. et al. Treatment of radiation-induced cystitis with hyperbaric oxygen. Journal of Urology 1985; 134: 352-354
• 22 Oscarsson N, Müller B, Rosén A. et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2–3 trial. Lancet Oncol 2019; 20: 1602-1614
• 23 Villeirs L, Tailly T, Ost P. et al. Hyperbaric oxygen therapy for radiation cystitis after pelvic radiotherapy: Systematic review of the recent literature. Int J Urol 2020; 27: 98-107
• 24 Shao Y, Lu GL, Shen ZJ. Comparison of intravesical hyaluronic acid instillation and hyperbaric oxygen in the treatment of radiation-induced hemorrhagic cystitis. BJU Int 2012; 109: 691-694
• 25 Gacci M, Saleh O, Giannessi C. et al. Sodium hyaluronate and chondroitin sulfate replenishment therapy can improve nocturia in men with post-radiation cystitis: results of a prospective pilot study. BMC Urol 2015; 15: 65
• 26 Sandhu SS, Goldstraw M, Woodhouse CRJ. The management of haemorrhagic cystitis with sodium pentosan polysulphate. BJU Int 2004; 94: 845-847
• 27 Hampson SJ, Woodhouse CRJ. Sodium pentosanpolysulphate in the management of haemorrhagic cystitis: experience with 14 patients. Eur Urol 1994; 25: 40-42
• 28 Singh I, Laungani GB. Intravesical epsilon aminocaproic acid in management of intractable bladder hemorrhage. Urology 1992; 40: 227-229
• 29 Liu YK, Harty JI, Steinbock GS. et al. Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen. J Urol 1990; 144: 41-43
• 30 Miller J, Burfield GD, Moretti KL. Oral conjugated estrogen therapy for treatment of hemorrhagic cystitis. J Urol 1994; 151: 1348-1350
• 31 Ordemann R, Naumann R, Geissler G. et al. Encouraging results in the treatment of haemorrhagic cystitis with estrogen – report of 10 cases and review of the literature. Bone Marrow Transplant 2000; 25: 981-985
• 32 Mousavi SA, Moazed V, Mohebbi N. et al. Conjugated Estrogen in Late-Onset Hemorrhagic Cystitis Associated with Hematopoietic Stem Cell Transplantation. Int J Hematol Oncol Stem Cell Res 2017; 11: 13
• 33 Heath JA, Mishra S, Mitchell S. et al. Estrogen as treatment of hemorrhagic cystitis in children and adolescents undergoing bone marrow transplantation. Bone Marrow Transplant 2006; 37: 523-526
• 34 Brennan S, Salib O, O’Shea C. et al. A randomized prospective study of extended tocopherol and pentoxifylline therapy, in addition to carbogen, in the treatment of radiation late effects. Ecancermedicalscience 2008; 2: 81
• 35 Magnusson M, Höglund P, Johansson K. et al. Pentoxifylline and vitamin E treatment for prevention of radiation-induced side-effects in women with breast cancer: A phase two, double-blind, placebo-controlled randomised clinical trial (Ptx-5). Eur J Cancer 2009; 45: 2488-2495
• 36 Delanian S, Porcher R, Balla-Mekias S. et al. Randomized, placebo-controlled trial of combined pentoxifylline and tocopherol for regression of superficial radiation-induced fibrosis. J Clin Oncol 2003; 21: 2545-2550
• 37 Abo-Salem OM. Uroprotective effect of pentoxifylline in cyclophosphamide-induced hemorrhagic cystitis in rats. J Biochem Mol Toxicol 2013; 27: 343-350
• 38 Veerasarn V, Khorprasert C, Lorvidhaya V. et al. Reduced recurrence of late hemorrhagic radiation cystitis by WF10 therapy in cervical cancer patients: a multicenter, randomized, two-arm, open-label trial. Radiother Oncol 2004; 73: 179-185
• 39 Phelps KR, Naylor K, Brien TP. et al. Encephalopathy after Bladder Irrigation with Alum: Case Report and Literature Review. Am J Med Sci 1999; 318: 181
• 40 Octavio Castillo A, Buizza C. Bladder irrigation with aluminum solution to control massive haematuria. Archivio Italiano di Urologia Nefrologia Andrologia 1989; 61: 59-62
• 41 Mukamel E, Lupu A, DeKernion JB. Alum irrigation for severe bladder hemorrhage. Journal of Urology 1986; 135: 784-785
• 42 Goswami AK, Mahajan RK, Nath R. et al. How safe is 1% alum irrigation in controlling intractable vesical hemorrhage?. Journal of Urology 1993; 149: 264-267
• 43 Barua SK, Das N, Baruah SJ. et al. Management of late hemorrhagic radiation cystitis in patients of carcinoma cervix with special reference to 1% alum irrigation and its safety: a clinical study in a tertiary care centre. International Journal of Advances in Medicine 2019; 6: 599
• 44 Ziegelmann MJ, Boorjian SA, Joyce DD. et al. Intravesical formalin for hemorrhagic cystitis: A contemporary cohort. Can Urol Assoc J 2017; 11: E79-E82
• 45 Comploj E, Pycha A, Trenti E. et al. Transarterial Embolization in the Management of Intractable Haemorrhage. Urol Int 2021; 105: 95-99
• 46 Piazza P, Rosiello G, Chacon VT. et al. Robot-assisted Cystectomy with Intracorporeal Urinary Diversion After Pelvic Irradiation for Prostate Cancer: Technique and Results from a Single High-volume Center. Eur Urol 2021; 80: 489-496
• 47 Cohn JA, Large MC, Richards KA. et al. Cystectomy and urinary diversion as management of treatment-refractory benign disease: The impact of preoperative urological conditions on perioperative outcomes. International Journal of Urology 2014; 21: 382-386
• 48 Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for refractory hemorrhagic cystitis: contemporary etiology, presentation and outcomes. J Urol 2014; 192: 1687-1692
• 49 Yeaman CT, Winkelman A, Maciolek K. et al. Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis. BMC Urol 2021; 21: 101