Non‐surgical interventions for late radiation cystitis in patients who have received radical radiotherapy to the pelvis

Abstract

Background

Chronic radiation cystitis occurs a minimum of three months after completion of pelvic radiotherapy and represents a range of clinical symptoms for which there is as yet no recommended standard management.

Objectives

The aim of this review was to identify the various non‐surgical treatment options for the management of late chronic radiation cystitis and evaluate the evidence.

Search methods

Synonyms for radiation therapy and for the spectrum of radiation toxicity to the bladder in both text and MeSH terms were combined and applied to a range of databases without restriction of year of publication, methodology or language.

Selection criteria

The inclusion criteria included studies of interventions for the non‐surgical management of all grades of late radiation cystitis.

Data collection and analysis

Out of 80 relevant studies, there were no RCTs that met the inclusion criteria, but there were three prospective case series and two non‐randomised studies which assessed different interventions and were not comparable.

Main results

Sixty‐three reports met the stated inclusion criteria. The majority were predominantly retrospective case series with the exception of two trials which were unrandomised and unblinded studies with a control group for comparison of effect. Although these two trials, Micic 1988, (intravesical placental extract) and Milani 1988, (flavoxate) provided the strongest evidence they were not randomised and were essentially isolated controlled studies.

Authors' conclusions

In such a relatively rare condition there are obvious difficulties in identifying sufficient patients to participate in a randomised controlled trial. The number of published reports is a reflection of the degree of medical interest that exists in providing therapeutic solutions for late radiation cystitis. However, in spite of the two studies of level IIA evidence, the absence of randomised controlled trials makes it impossible to draw any firm conclusions.

Author(s)

Arshi S Denton, Noel Clarke, Jane Maher

Abstract

Plain language summary

No evidence from trials on the effects of non‐surgical treatments for late radiation cystitis, and more research on drugs inserted into the bladder is worthwhile

Radiotherapy to the pelvic area for gynaecological cancer can damage the bladder in some women. This can lead to late radiation cystitis, which can cause urinary problems (including pain), blood in the urine, reduced bladder capacity and/or bladder damage. There can be a cycle of bleeding, infection and occasionally life‐threatening complications. Options include treating infections, blood transfusion, catheters (tubes) to release urine, drugs inserted into the bladder, and surgery. The review found there is no evidence from trials to determine the effects of non‐surgical treatments for late radiation cystitis, although some drugs inserted into the bladder might help.

Author(s)

Arshi S Denton, Noel Clarke, Jane Maher

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

In a relatively rare condition there are obvious difficulties in identifying enough cases to participate in a randomised controlled trial. The number of published reports is a reflection of the degree of medical interest that exists in providing treatments for the managment of late radiation cystitis. Unfortunately the small numbers in the case series and methodology means that the data derived, although impressive, is of a low level of evidence and although of interest, is not of a high enough calibre to influence current trends in clinical practice other than that based on anecdotal and experiential knowledge. However they could form the basis of a multicentre randomised controlled trials to provide the evidence to subsequently implement changes and make recommendations. This would require a consensus of opinion from a multidisciplinary group of clinicians with experience in this field to decide on the specific characteristics for defining late radiation cystitis, the use of a universally accepted grading system and a hierarchy of the most effective treatment options from those listed in the review.

Implications for research 

One way of increasing the number of cases with confirmed late radiation cystitis that may be suitable for treatment with the interventions outlined would be to create a database of such cases with central registration, uniform baseline assessments and formal standardised grading of the toxicity. In such a setting interventions could be administered in a multicentre trial so that small numbers of cases per centre could be pooled to provide results with consistently performed outcome assessments and significant clinical impact. Given the implications of late radiation toxicity this would be an ideal opportunity to collect parallel data regarding the effect that the treatment offered has on quality of life issues but would require appropriate recognition, funding, manpower and commitment to institute this in practical terms.

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