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Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitis due to carcinoma cervix: a study from a tertiary care hospital in South India John Samuel Banerji, Antony Devasia, Nitin Sudhakar Kekre and Ninan Chacko Department of Urology, Christian Medical College, Vellore, India
Key words radiation cystitis, ileal conduit, vesicovaginostomy. Correspondence Dr John Samuel Banerji, Department of Urology, Christian Medical College, Vellore 632004, India. Email: [email protected] J. S. Banerji MS, MCh, DNB; A. Devasia MS, MCh, FRCS(Ed); N. S. Kekre MS, DNB; N. Chacko MS, MCh, FRCS. Accepted for publication 21 September 2014. doi: 10.1111/ans.12898
Abstract Background: To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy. Methods: Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis. Results: Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature. Conclusion: In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, costeffective approach with good quality of life and early return to normal activity.
Introduction Radiation therapy is an important armamentarium in the treatment of pelvic malignancies. However, the bladder and the rectum do often get inadvertently irradiated, especially in the pre-intensitymodulated radiation therapy era. Radiation cystitis has a significant morbidity, requiring recurrent hospital admissions. Added to this is the burden of recurrent transfusions, with its attendant risk of blood-borne infections. Although modalities like alum instillation and hyperbaric oxygen have been used, long-term efficacy data is lacking. Carcinoma cervix being predominantly a disease of the lower socio-economic group, economics begins to further dictate management protocols. As there were no recommended guidelines, we embarked on this retrospective study to determine if we could formulate a management protocol for severe radiation cystitis. ANZ J Surg 85 (2015) 770–773
The aim of this study was to evaluate the magnitude of radiation cystitis following radiation therapy, for carcinoma cervix, and to assess the impact of urinary diversion as a treatment modality in the more severe forms of radiation cystitis. A cost analysis comparing repeated admissions to early diversion was also performed.
Methodology This was a retrospective study spanning from January 1998 to December 2011, with approval of the institutional review board. Electronic data review of patients who received radiotherapy for carcinoma cervix was obtained. All patients who had symptoms suggestive of radiation cystitis according to the common toxicity criteria viz. burning micturition, increased frequency, haematuria, incontinence, renal failure were initially evaluated. They were then categorized according to the © 2014 Royal Australasian College of Surgeons
Early urinary diversion for severe radiation cystitis
771
Radiation Therapy Oncology Group grading for radiation cystitis, into the mild (grades 1 and 2) cystitis, and the severe cystitis (grades 3 and 4). The study groups were the ones with severe radiation cystitis (grades 3 and 4). The parameters studied were time interval from radiation to the development of cystitis, dosage of radiation received, requirement of transfusions, number of admissions, cost for each admission and cost of diversion procedure. The initial management of all patients who presented with a first episode of haematuria was a bladder wash. At the time of bladder wash, obvious bleeding points were fulgurated, using a monopolar, underwater diathermy through a resectoscope. Patients were then catheterized with a 22-Fr three-way catheter, and their bladders irrigated with normal saline for at least 24 h. Subsequently, they were instructed to avoid overdistension of the bladder and were instructed on frequent, timed voiding habits. Over the past 6 years, we began offering patients diversion, with an aim of improving quality of life and decreasing cost. Patients were deemed candidates for diversion if the haematuria was recurrent, necessitating more than three admissions. Patients were deemed suitable for diversion, only after ensuring that there was no recurrence of disease. These patients underwent a thorough gynaecological examination and contrast enhanced computerized tomography scan of the abdomen. Those who had elevated creatinine at presentation underwent ultrasonography of the abdomen, for upper tract evaluation. Initially, we were only performing an ileal conduit diversion. However, as the bladder was being left intact, there was a theoretical possibility of developing pyocystitis, and hence during the latter part of the study, a vesicovaginostomy was also incorporated. Vesicovaginostomy was performed using a Collin’s knife used through a resectoscope. The resectoscope was inserted into the bladder, and a full thickness ‘perforation’ was created into the vagina, ensuring that the bladder secretions would drain into the vagina. Statistical analysis was done using SPSS version 16 (SPSS Inc, Chicago, IL, USA).
The 62 patients with severe cystitis were subsequently analysed. Earlier, patients were being managed with bladder washes, fulguration and transfusions. Of these, 12 had multiple bladder washes (more than three times). Four patients received intravesical alum (1%), and two patients even had 1% formalin instillation. The flow chart of management is given in Figure 1. As there was no agreed protocol or guidelines anywhere in literature, these patients, during the earlier years, were managed according to surgeon choices and preferences. These patients constituted group A (n = 34). During the last 8 years, we have changed our policy of management, and are offering diversion in patients who have recurrent haematuria, multiple admissions and transfusions. These constituted group B (n = 28). As can be seen from Table 2, the mean age of onset was similar in the two groups. However, the time interval to onset of cystitis (P = 0.0027, CI 0.5425 to 2.4575), the mean number of transfusions (P =
Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitis due to carcinoma cervix: a study from a tertiary care hospital in South India John Samuel Banerji, Antony Devasia, Nitin Sudhakar Kekre and Ninan Chacko Department of Urology, Christian Medical College, Vellore, India
Key words radiation cystitis, ileal conduit, vesicovaginostomy. Correspondence Dr John Samuel Banerji, Department of Urology, Christian Medical College, Vellore 632004, India. Email: [email protected] J. S. Banerji MS, MCh, DNB; A. Devasia MS, MCh, FRCS(Ed); N. S. Kekre MS, DNB; N. Chacko MS, MCh, FRCS. Accepted for publication 21 September 2014. doi: 10.1111/ans.12898
Abstract Background: To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy. Methods: Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis. Results: Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature. Conclusion: In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, costeffective approach with good quality of life and early return to normal activity.
Introduction Radiation therapy is an important armamentarium in the treatment of pelvic malignancies. However, the bladder and the rectum do often get inadvertently irradiated, especially in the pre-intensitymodulated radiation therapy era. Radiation cystitis has a significant morbidity, requiring recurrent hospital admissions. Added to this is the burden of recurrent transfusions, with its attendant risk of blood-borne infections. Although modalities like alum instillation and hyperbaric oxygen have been used, long-term efficacy data is lacking. Carcinoma cervix being predominantly a disease of the lower socio-economic group, economics begins to further dictate management protocols. As there were no recommended guidelines, we embarked on this retrospective study to determine if we could formulate a management protocol for severe radiation cystitis. ANZ J Surg 85 (2015) 770–773
The aim of this study was to evaluate the magnitude of radiation cystitis following radiation therapy, for carcinoma cervix, and to assess the impact of urinary diversion as a treatment modality in the more severe forms of radiation cystitis. A cost analysis comparing repeated admissions to early diversion was also performed.
Methodology This was a retrospective study spanning from January 1998 to December 2011, with approval of the institutional review board. Electronic data review of patients who received radiotherapy for carcinoma cervix was obtained. All patients who had symptoms suggestive of radiation cystitis according to the common toxicity criteria viz. burning micturition, increased frequency, haematuria, incontinence, renal failure were initially evaluated. They were then categorized according to the © 2014 Royal Australasian College of Surgeons
Early urinary diversion for severe radiation cystitis
771
Radiation Therapy Oncology Group grading for radiation cystitis, into the mild (grades 1 and 2) cystitis, and the severe cystitis (grades 3 and 4). The study groups were the ones with severe radiation cystitis (grades 3 and 4). The parameters studied were time interval from radiation to the development of cystitis, dosage of radiation received, requirement of transfusions, number of admissions, cost for each admission and cost of diversion procedure. The initial management of all patients who presented with a first episode of haematuria was a bladder wash. At the time of bladder wash, obvious bleeding points were fulgurated, using a monopolar, underwater diathermy through a resectoscope. Patients were then catheterized with a 22-Fr three-way catheter, and their bladders irrigated with normal saline for at least 24 h. Subsequently, they were instructed to avoid overdistension of the bladder and were instructed on frequent, timed voiding habits. Over the past 6 years, we began offering patients diversion, with an aim of improving quality of life and decreasing cost. Patients were deemed candidates for diversion if the haematuria was recurrent, necessitating more than three admissions. Patients were deemed suitable for diversion, only after ensuring that there was no recurrence of disease. These patients underwent a thorough gynaecological examination and contrast enhanced computerized tomography scan of the abdomen. Those who had elevated creatinine at presentation underwent ultrasonography of the abdomen, for upper tract evaluation. Initially, we were only performing an ileal conduit diversion. However, as the bladder was being left intact, there was a theoretical possibility of developing pyocystitis, and hence during the latter part of the study, a vesicovaginostomy was also incorporated. Vesicovaginostomy was performed using a Collin’s knife used through a resectoscope. The resectoscope was inserted into the bladder, and a full thickness ‘perforation’ was created into the vagina, ensuring that the bladder secretions would drain into the vagina. Statistical analysis was done using SPSS version 16 (SPSS Inc, Chicago, IL, USA).
The 62 patients with severe cystitis were subsequently analysed. Earlier, patients were being managed with bladder washes, fulguration and transfusions. Of these, 12 had multiple bladder washes (more than three times). Four patients received intravesical alum (1%), and two patients even had 1% formalin instillation. The flow chart of management is given in Figure 1. As there was no agreed protocol or guidelines anywhere in literature, these patients, during the earlier years, were managed according to surgeon choices and preferences. These patients constituted group A (n = 34). During the last 8 years, we have changed our policy of management, and are offering diversion in patients who have recurrent haematuria, multiple admissions and transfusions. These constituted group B (n = 28). As can be seen from Table 2, the mean age of onset was similar in the two groups. However, the time interval to onset of cystitis (P = 0.0027, CI 0.5425 to 2.4575), the mean number of transfusions (P =
![[A 17-year experience with ileal conduit urinary diversion--early and late complications].](/assets/img/hold.png)
