Hemorrhagic Cystitis Following Radiotherapy for Stage Ib Cancer of the Cervix

Our purpose was to study the incidence, severity, timing, clinical management, and outcome for patients who developed hemorrhagic cystitis following pelvic radiotherapy for stage Ib cancer of the cervix. A total of 1784 patients with stage Ib cancer of the cervix were treated with pelvic radiotherapy at the University of Texas M. D. Anderson Cancer Center between 1960 and 1989. The majority received a combination of external-beam and intracavitary treatments. Patients with hemorrhagic cystitis were identified through retrospective review of their medical records, and a grade was assigned to each occurrence. A total of 116 (6.5%) patients with hemorrhagic cystitis were identified. The initial occurrence was grade 1 (minor occurrence) in 59%, grade 2 (repeated minor bleeding) in 23%, and grade 3 (hospitalization for medical management) in 18%. The median interval from the beginning of radiotherapy to the onset of hematuria was 35.5 months (mean 58 months). The median time to initial grade 3 occurrences was 37.5 months (mean 84 months). Actuarial life table analysis revealed that the risk of hematuria is 5.8% at 5 years, 7.4% at 10 years, and 9.6% at 20 years. The risk for a grade 3, 4 (requiring surgical intervention), or 5 (death) complication is 1.0, 1.4 and 2.3% at 5, 10, and 20 years, respectively. Approximately one-third of the patients with a grade 3 occurrence were rehospitalized for management of bladder complications a median of 3.5 months following the first grade 3 occurrence, although some of these readmissions occurred many years later. Associated urinary-tract infection was common. In no case did a cystoscopic bladder biopsy reveal recurrent tumor or a second primary tumor when visual inspection revealed typical radiation changes. The incidence of severe hemorrhagic cystitis following radiation for stage Ib cancer of the cervix is low and can occur many years following treatment. Minor episodes of hematuria are managed by empiric antibiotic therapy until the results of urine cultures are available. Cystoscopy is reserved for patients with persistent bleeding to rule out clot retention or the slight possibility of a second primary tumor or recurrent disease. Biopsy should be avoided if obvious radiation changes are present. Clot evacuation and continuous bladder irrigation remain the standard treatment for patients with heavy bleeding.