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Apollo Medicine 2012 JuneVolume 9, Number 2; pp. 151e153 Case Study

Use of hyperbaric oxygen therapy in management of radiation cystitis

Tarun Sahnia,*, Puneet Guptab

aSenioSarita*CorreReceivCopyridoi:10.

ABSTRACT

Radiation induced tissue injury is a result of progressive endarteritis which leads to hypovascular, hypocellular andhypoxic tissues. This damage begins as soon as patient is exposed to radiation beam. Most patients experiencesome acute side effects and it is rare and serious event when late side effects develop. Radiation cystitis is a latecomplication of radiotherapy for pelvic malignancies like prostate and cervix. Although 85% of the cases resolve withconservative management, the remainder become refractory and progress to involve a more extensive area of bonyand soft tissue. Hyperbaric oxygen therapy (HBOT) is used to treat various forms of chronic radiation tissue injury andis a potential primary option for management of radiation cystitis by enhancing healing in such cases by increasingvascular density and oxygen levels in irradiated tissues. We report a case of 60-year-old male with radiation cystitiswho showed promising improvement and resolution of his symptoms after forty HBOT sessions.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Radiation cystitis, Hyperbaric oxygen therapy, Pelvic cancer, Radionecrosis

INTRODUCTION

Radiotherapy is a major non operative treatment andcommonly used in management of a number of malignan-cies.1,2 From past few years, development in delivery ofradiotherapy has improved the efficacy and tolerance butadverse effects continue to complicate its use. These effectsare commonly categorized as either acute effects that occurduring or in immediate post irradiation period and aremostly self limiting or late effects that manifest manymonths to several years later and are slower to heal.

Depending on patient’s sensitivity to radiotherapy, typeand dose of treatment, patients experience scarring and nar-rowing of blood vessels within the treatment area leading toinadequate blood supply which result in damage to softtissues and bones causing osteoradionecrosis, radiationcystitis and radiation proctitis etc.3e6

Radiation cystitis is not a common complication butoccurs in as many as 15e20% of patients receiving

r Consultant, Department of Internal and Hyperbaric Medicine,bSenioVihar, Delhi-Mathura Road, New Delhi 110076, India.sponding author. Tel.: þ91 9810038010; fax: þ011 26823629, emaied: 19.4.2012; Accepted: 30.4.2012; Available online: 8.5.2012ght � 2012, Indraprastha Medical Corporation Ltd. All rights reserved1016/j.apme.2012.04.004

high doses of radiotherapy for management of genitouri-nary cancers. It occurs at least 90 days after initiation ofradiation therapy but may occur in delayed manner evenbeyond 10 years. Radiation therapy leads to hypovascu-lar, hypocellular and hypoxic tissues causing cellulardepletion, fibrosis causing reduction in bladder capacityand patients present with lower urinary tract storagesymptoms such as urgency, frequency and dysuria.3e9

The treatment of this entity depends on its extent andseverity and ranges from simple conservative methodsto radical surgery.

Hyperbaric oxygen therapy (HBOT) is a primary treat-ment option that reverses vascular compromise in suchpatients by stimulating angiogenesis, fibroblast proliferationand improved tissue oxygenation within the affectedareas.7,9,10 HBOT for radiation cystitis is non invasiveand well tolerated modality with very encouragingoutcomes in this complex problem when administeredalone or as an adjunctive treatment.

r Consultant, Department of Oncology, Indraprastha Apollo Hospital,

l: aimhu@livein

.

Table 1 Improvement of symptoms of patient during different phases of treatment.

Symptoms Before HBOT After 20 sessions After 40 sessions

Urinary frequency in a day 14 10 7Dysuriaa 5 2 0Bladder capacity (ml) 200 200e250 >300Nocturia 6 times 3 times 2 timesPelvic paina 2 0 0a Visual Analogue Scale used for pain estimation (0 means no pain and 10 is maximum pain ever experienced).

152 Apollo Medicine 2012 June; Vol. 9, No. 2 Sahni and Gupta

CASE REPORT

A 60-year-old normotensive, euglycemic gentleman devel-oped radiation induced cystitis after being treated formanagement of prostate cancer with 30 fractions of radia-tion therapy (60 Gy) and radical prostectomy in 2009.

He presented with a history of increased urinefrequency, incontinence and haematuria since 8 months.There was no other relevant medical history. His ultrasoundKUB revealed cystitis changes showing clot in urinarybladder with large Post Void Urine (445 cc). It also indi-cated bilateral hydronephrosis and hydroureter. His prostateserum antigen (PSA) level was found to be 0.06 ng/ml. Heunderwent cystoscopy in January 2011 with 19 F sheath forclot evacuation which revealed patches of radiation cystitislateral to left ureteric orifice.

Along with the medical treatment, the patient wasreferred for HBOT for resolution of his symptoms andwas scheduled for 20 sessions. He showed slow but prom-ising progress and was advised for further 20 sessions. Thepatient underwent forty, 90-minute treatment at 2.4 atmo-sphere absolute (ATA) in a multiplace hyperbaric oxygenchamber at our centre.

On completion of hyperbaric treatment, patient haddecreased urinary frequency and daily voiding reducedfrom 14 to 7 times per day. He reported improvement inpain scale from baseline 5 on Visual Analogue Scale(VAS) to zero after forty HBOT sessions. The patient hadno episode of haematuria with reduced pelvic pain. Therewas increased bladder capacity with reduced urinaryfrequency at night. Table 1 shows improvement in hissymptoms during different phases of HBO treatment.

DISCUSSION

Radiation cystitis is a challenging complication in themanagement of genitourinary cancer. It manifests as pres-ence of haematuria, incontinence, dysuria and nocturiawith tissue ischaemia as its underlying mechanism. It leadsto progressive endarteritis, hypovascular, hypocellular and

hypoxic tissue (the ‘three-H’ tissue) resulting in reducedability to replace normal collagen and compromised cellularloss which causes difficulty in healing.6,8e10 HBO results inan increased diffusion gradient which forces oxygen intothe damaged urothelial tissues and also stimulates angio-genesis with fibroblast proliferation in the irradiatedareas.5,8e10

The case we treated with HBO showed significantdecrease of urinary frequency and pelvic pain along withincreased bladder capacity. It was well tolerated and noadverse effects were seen. HBO for radiation cystitis is aneffective and safe treatment with encouraging outcomes.

CONCLUSION

HBO therapy is a non invasive modality for treating theunderlying changes that occur with radiation injury, result-ing in resolution of symptoms in patients with radiationcystitis.

ACKNOWLEDGEMENT

We would like to thank Dr Rajesh Ahlawat from MedantaHospital and for referral of this patient and research coordi-nators in hyperbaric team Ms Shweta and Ms Sapna fortheir assistance.

REFERENCES

1. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS,Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunc-tive treatment for delayed radiation injuries of the abdomenand pelvis. Undersea Hyperb Med. 1997;23(4):205e213.

2. Woo TCS, Joseph D, Oxer H. Hyperbaric oxygen treatmentfor radiation proctitis. Int J Radiat Oncol Biol Phys. 1997;38(3):619e622.

3. Chong KT, Hampson NB, Corman JM. Early hyperbaricoxygen therapy improves outcome for radiation-inducedhemorrhagic cystitis. Urology. 2005;65(4):649e653.

HBOT in radiation cystitis Case Study 153

4. Focosi D, Maggi F, Pistolesi D, et al. Hyperbaric oxygentherapy in BKV-associated hemorrhagic cystitis refractory tointravenous and intravesical cidofovir: case report and reviewof literature. Leuk Res. 2009;33:556e560.

5. Williams JA, Clarke D, Dennis WA, et al. The treatment ofpelvic soft tissue radiation necrosis with hyperbaric oxygen.Am J Obstet Gynecol. 1992;167(2):412e416.

6. Marx RE. Radiation injury to tissue. In: Whelan HT,Kindwall EP, eds. Radiation Injury to Tissue. HyperbaricMedicine Practice. 3rd ed. Best Publishing; 2008:853e903.

7. Bevers RFM, Bakker DJ, Kurth KH. HBO treatment for hae-morrhagic radiation cystitis. Lancet. 1995;346:803e805.

8. Corman JM, McClure D, Pritchett R, et al. Treatment of radi-ation induced hemorrhagic cystitis with hyperbaric oxygen.J Urol. 2003;169:2200e2202.

9. Del Pizzo JJ, Chew BH, Jacobs SC, et al. Treatment of radia-tion induced hemorrhagic cystitis with hyperbaric oxygen:long-term follow-up. J Urol. 1998;160:731e733.

10. Janda M, Newman B, Obermair A, et al. Impaired quality oflife in patients commencing radiotherapy for cancer. Strah-lenther Onkol. 2004;180:78e83.

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