Hyperbaric Oxygen Therapy in Reconstructive Urology and Urogynecology
Hyperbaric oxygen therapy (HBOT) uses oxygen at increased ambient pressure. Its best randomized evidence in urology concerns selected patients with chronic radiation cystitis. Evidence for Fournier's gangrene, recurrent fistulas, and perioperative graft conditioning is chiefly observational; those indications should not be presented as proven reductions in mortality or reconstructive failure.[1][2][3][4]
See Wound-Healing Adjuncts, Radiation Tissue Effects, and Conservative Management of RUF.
Mechanism and Treatment Delivery
HBOT increases dissolved plasma oxygen. Experimental and translational work describes effects on oxygen diffusion, inflammatory signaling, fibroblasts, angiogenesis, and antimicrobial activity. These mechanisms provide biological rationale, but do not establish clinical benefit for every hypoxic wound or GU repair.[5][6][7][8][9]
The pressure, oxygen-exposure time, air breaks, and number of sessions are prescribed by a hyperbaric service for the indication. RICH-ART used 30–40 sessions, 100% oxygen at 240–250 kPa, for 80–90 minutes, five days per week. Oxygen-exposure time is distinct from total attendance including compression and decompression. Acute infection protocols differ from a six- to eight-week outpatient radiation-injury course.[1][10]
There is no established single optimal pressure for radiation cystitis. A 2026 two-site retrospective comparison of 93 patients associated 2.5 ATA with less recurrent gross hematuria than 2.0 ATA, but more adverse events; it does not establish a causal dose advantage.[11]
Radiation Cystitis: What the Trials Establish
RICH-ART 2019 was an open-label randomized trial: 87 randomized, 79 in the reported initial analysis after eight immediate consent withdrawals. At six to eight months, improvement in the EPIC urinary total score was 10.1 points greater with HBOT than standard care (95% CI 2.2–18.1). This was a patient-reported urinary-symptom endpoint, not a hematuria-remission or survival endpoint.[1]
The trial excluded recent bleeding requiring more than 500 mL transfusion in four weeks, permanent urinary catheterization, bladder capacity below 100 mL, and bladder fistula. Its results therefore do not establish HBOT as emergency hemostasis or as treatment of an established urinary fistula.[1]
The 2025 five-year report followed patients after controls were offered HBOT. It was a single-group longitudinal analysis, not a continuing randomized comparison. Seventy entered follow-up; 39 had five-year measurements. The modeled mean EPIC urinary improvement at five years was 19.1 points (95% CI 13.3–24.9); 9/70 received additional HBOT for recurrent symptoms. This supports durability in some patients, with substantial missing follow-up and no untreated long-term control. It did not demonstrate randomized cost savings, fewer transfusions, or lower mortality.[12]
For hematuria counseling, a separate 2024 synthesis of 14 studies and 556 patients estimated approximately 55% complete remission. This heterogeneous pooled estimate is not the RICH-ART response rate and is not a guarantee for an individual patient.[13]
Evaluate other causes of hematuria and treat clot retention or unstable bleeding promptly. HBOT can be discussed for persistent radiation injury with the treating urologist and hyperbaric team; patient stability, symptom burden, previous treatment, and access guide its place in care.
Radiation Proctitis and Broader Late Radiation Injury
Randomized findings for bowel symptoms differ:
| Evidence | Finding and limit |
|---|---|
| HORTIS 2008, sham-controlled trial | Reported benefit in refractory radiation proctitis; assessed a different population and primary time point from HOT2[14] |
| HOT2 2016, 84 randomized | 2.4 ATA, 40 treatments, versus sham at 1.3 ATA. No significant difference in the co-primary bowel-function or rectal-bleeding scores at 12 months. The trial was not a 2.0-ATA underdosing experiment; severely transfusion-dependent bleeding was underrepresented[15] |
| ASCRS 2018 guideline | Recommends HBOT to reduce bleeding in chronic radiation proctitis, graded 1B; this is a proctitis recommendation, not a cystitis or fistula recommendation[16] |
| Cochrane 2023, 18 RCTs, 1,071 participants across radiation-injury sites | Suggests benefit for some selected late radiation injuries, with low-to-moderate certainty and important limitations. Head/neck wound results should not be treated as proof of improved GU reconstruction[17] |
Uncontrolled proctitis series report substantial symptom responses, but selection, missing follow-up, outcome definitions, and additional treatment prevent a direct comparison with the trials.[18][19]
Fournier's Gangrene and Necrotizing Soft-Tissue Infection
Urgent debridement, antibiotics, resuscitation, and repeat source control remain central. HBOT must not delay these treatments or compromise intensive care. Reviews and guidelines differ on adjunctive HBOT; routine benefit has not been established by adequately controlled randomized evidence.[10][20]
Toppen's 2024 retrospective NIS study included 60,481 surgically treated NSTI admissions, of which 600 received HBOT. The adjusted mortality odds ratio was 0.22 (95% CI 0.09–0.53). This is an association in mixed-site NSTI, not a proven 78% mortality reduction specifically for Fournier's gangrene. Treatment timing, physiological severity, and selection were incompletely captured, leaving substantial confounding.[3]
Older small Fournier cohorts produced conflicting findings: Hollabaugh reported lower mortality with HBOT, whereas Mindrup did not. Neither resolves causality or identifies who should routinely receive it.[21][22]
Complex Fistulas and Persistent Perineal Sinus
Hammad 2026 compared 53 HBOT-treated patients with matched controls undergoing repair of perianal, rectovaginal, or pouch-vaginal fistulas. Overall six-month healing was not significantly different (84.9% versus 76.3%; p=0.18), nor was overall recurrence. Signals after stoma reversal and in multiply operated patients are exploratory and confounded by baseline differences; this was not a rectourethral-fistula trial.[2]
In Marguet's six-patient series of radiation-associated RUF, all four patients who received HBOT failed that approach. HBOT should not be represented as a reliable stand-alone closure treatment for radiation-associated RUF, or used to postpone appropriate diversion and reconstruction.[23]
Chan reported healing in four highly selected patients treated with both sinus excision/RAM-flap reconstruction and perioperative HBOT. The contribution of HBOT cannot be separated from surgery; four successful cases do not establish a universal treatment protocol.[24]
Hypospadias Reoperations and Tissue Conditioning
Bush and Snodgrass compared 32 HBOT recipients with 25 nonrecipients during staged oral-graft hypospadias reoperations. The reported percentage graft-area contraction was 9% versus 26%; graft failure, defined as at least 50% contracture, occurred in 6% versus 28%. The first pair of percentages describes the degree of contraction, not the proportion of patients developing contracture.[4]
Treatment was offered particularly after three or more failed repairs, using 20 preoperative and 10 postoperative sessions. Prior repair burden, insurance, and local availability influenced treatment allocation. This is a hypothesis-generating comparative cohort, not randomized proof or a general requirement for urethroplasty or other grafts.[4]
A 2020 review of 13 perioperative RCTs found heterogeneous procedures, outcomes, and methodological weaknesses. Counting studies with at least one positive outcome does not establish an overall benefit for pelvic reconstruction. Preoperative “tissue conditioning” remains incompletely tested for these specific operations.[25][26]
Radiation-Induced Vaginal Injury
A 2025 retrospective series found improvement in at least one symptom in 15/19 patients. It excluded fistulas and patients completing fewer than 20 sessions; the response definition and selection limit generalization. Improvement in a symptom is not equivalent to reversal of all stenosis or fibrosis.[27]
Earlier observational experience and a 2022 systematic review support further evaluation for refractory vaginal radiation injury, particularly nonhealing soft-tissue injury. Discuss HBOT as a selected adjunct, with oncology assessment and examination for recurrent malignancy where appropriate; the evidence does not establish a 79–100% expected cure rate.[28][29]
Other Proposed GU Uses
| Application | Current interpretation |
|---|---|
| IC/BPS | A 21-patient sham-controlled trial had three responders among 14 HBOT recipients and none among seven controls, without a significant between-group response difference. Within-group pain/urgency changes and a six-person pilot do not establish routine efficacy[30][31][32] |
| Nonsurgical ED | An uncontrolled 30-man study reported an 88% relative increase in the erectile-function score, not an 88% patient cure rate. MRI perfusion changes do not prove clinically meaningful new-vessel formation or durable restoration[33] |
| Post-prostatectomy ED | In a blinded trial of 109 randomized men, 83 completed 18-month follow-up; no significant erectile-recovery advantage was detected. Routine penile rehabilitation with HBOT is unsupported[34] |
| Mesh infection/complications | One postoperative cellulitis case improved with antibiotics plus HBOT. It cannot establish infected-mesh salvage efficacy or replace drainage, explantation, or other source control when indicated[35] |
| Other chronic wounds | Lower-limb ulcer evidence is indication-specific and does not establish efficacy for every chronic GU wound[36] |
Safety and Practical Selection
Screening and treatment require a qualified hyperbaric service. Untreated pneumothorax is an absolute contraindication. Respiratory disease with air trapping, difficulty equalizing ear/sinus pressure, seizure history, cardiovascular disease, severe claustrophobia, and pregnancy require individual assessment. Pregnancy is not an absolute bar to treatment for a life-threatening indication.[37][38]
Review recent chemotherapy and other relevant drugs with the treating teams. Doxorubicin, cisplatin, and previous bleomycin lung injury raise different timing/toxicity concerns; they should not be compressed into a universal permanent contraindication. Likewise, an upper respiratory infection may impair pressure equalization, but “any active viral disease” is not a contemporary blanket absolute contraindication. Verify implanted-device pressure compatibility.[37][38]
Common problems include ear discomfort/barotrauma, transient visual refractive changes, and confinement anxiety. Oxygen-toxicity seizures and pulmonary complications are less common but require appropriate monitoring and response. Risks depend on patient characteristics and the treatment regimen; rates per session cannot be substituted for rates per patient or course. In RICH-ART, 17/41 treated patients reported transient grade 1–2 sight/hearing-related adverse events.[1][39][37]
Check glucose when clinically indicated, particularly in patients using insulin, and follow the facility's oxygen/fire-safety procedures. Prior malignancy alone does not exclude HBOT, but suspected recurrence still needs investigation; HBOT is not an anticancer treatment.[37][38]
Access, Cost, and Counseling
A radiation-injury course commonly means several weeks of repeated visits. Discuss travel, treatment burden, coverage, likely symptom targets, and alternatives. Historical hospital charges are not current treatment prices, and the RICH-ART five-year follow-up is not a randomized cost-effectiveness analysis.[12][22]
The underlying problem still needs treatment: HBOT cannot correct an undrained infection, mechanical obstruction, unsuitable wound bed, or an anatomic fistula merely by increasing oxygen exposure.[40]
References
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2. Hammad AF, Erkaya M, Hull TL, et al. "Impact of hyperbaric oxygen therapy on complex perineal fistula healing." Colorectal Dis. 2026;28(3):e70398. doi:10.1111/codi.70398
3. Toppen W, Cho NY, Sareh S, et al. "Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections." PLoS One. 2024;19(3):e0300738. doi:10.1371/journal.pone.0300738
4. Bush N, Snodgrass W. "Hyperbaric oxygen therapy improves oral graft take in hypospadias staged tubularized autograft reoperations." J Urol. 2019;202(3):617–622. doi:10.1097/JU.0000000000000145
5. Tejada S, Batle JM, Ferrer MD, et al. "Therapeutic effects of hyperbaric oxygen in the process of wound healing." Curr Pharm Des. 2019;25(15):1682–1693. doi:10.2174/1381612825666190703162648
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15. Glover M, Smerdon GR, Andreyev HJ, et al. "Hyperbaric oxygen for patients with chronic bowel dysfunction after pelvic radiotherapy (HOT2): a randomised, double-blind, sham-controlled phase 3 trial." Lancet Oncol. 2016;17(2):224–233. doi:10.1016/S1470-2045(15)00461-1
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18. Moreira Monteiro A, Alpuim Costa D, Mareco V, Espiney Amaro C. "The effectiveness of hyperbaric oxygen therapy for managing radiation-induced proctitis — results of a 10-year retrospective cohort study." Front Oncol. 2023;13:1235237. doi:10.3389/fonc.2023.1235237
19. Oscarsson N, Arnell P, Lodding P, Ricksten SE, Seeman-Lodding H. "Hyperbaric oxygen treatment in radiation-induced cystitis and proctitis: a prospective cohort study on patient-perceived quality of recovery." Int J Radiat Oncol Biol Phys. 2013;87(4):670–675. doi:10.1016/j.ijrobp.2013.07.039
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