Gross Hematuria in Patients with Prostate Cancer: Etiology and Management

The objective of the study is to assess the etiology and prognosis of gross hematuria (GH) in patients with carcinoma of the prostate (CAP). From 1991 to 2011, 81 men (mean age 74.3 years, SD 6.5) with CAP were hospitalized with GH. Primary treatment of CAP was radical surgery in 13 patients (group 1) and nonsurgical therapy in 68 (group 2), mostly radiotherapy (35 cases) and hormonal treatment (25 cases). The common etiologies of GH in group 1 were bladder cancer (38.5%) and urinary infection (23%). In contrast, CAP itself caused GH in 60% of the patients in group 2. Thirty-nine patients (48%) required transurethral surgery to manage GH which was effective in all cases; nevertheless, the prognosis of group 2 patients was dismal with median overall survival of 13 months after sustaining hematuria, compared to 50 months in group 1 ( ). We conclude that the etiology of GH in patients with CAP varies according to primary treatment. After radical prostatectomy, it is habitually caused by bladder cancer or infection. When the primary treatment is not surgical, GH is most commonly due to CAP itself. Although surgical intervention is effective in alleviating hematuria of these patients, their prognosis is dismal. 1. Introduction The frequency of GH in patients with CAP is unknown. GH can be a result of CAP itself, a side effect of previous treatments (acute or chronic toxicity of radiotherapy, stone formation on a suture after surgery) or unrelated to CAP. GH after external beam radiotherapy is not uncommon, but is usually mild and self-limited [1]. Its occurrence is dependent on bladder wall dose-volume [2], and it is more frequent in patients that had previous transurethral prostatectomy [3]. Macrohematuria after brachytherapy is rare (less than 1%) [4]. It seems that hormonal therapy is a protective factor for late hematuria after high-dose radiotherapy for CAP [5]. The effect of finasteride, known to prevent GH due to benign prostatic enlargement [6] in patients with malignant disease, is unknown. The frequency of GH after radical prostatectomy and cryotherapy and in patients receiving hormonal treatment is not documented in the literature. The management of GH in patients with CAP can be quite difficult. Various treatments were suggested including finasteride, radiotherapy, antifibrinolytics, bladder irrigations with alum solution and transurethral surgery, and angioembolization, none with proven effectiveness [7]. Total pelvic exenteration was also suggested in desperate cases [8]. GH in patients with CAP is, therefore, a complex condition. Multiple