Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer

Abstract

ObjectiveTo describe the management of Radiation Therapy Oncology Group (RTOG) grade 4 urinary adverse events (UAEs) after radiotherapy (RT) for prostate cancer (PCa). MethodsWe conducted a single-centre retrospective review, over a 6-year period (2010)(2011)(2012)(2013)(2014)(2015), to identify men with RTOG grade 4 UAEs after RT for PCa. RT was classified as combined therapy (radical prostatectomy [RP] followed by external beam radiotherapy [EBRT], EBRT + low-dose-rate [LDR] brachytherapy, EBRT + high-dose-rate [HDR] brachytherapy or other combinations of RT) or monotherapy RT. UAEs were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, or recto-urethral fistula) or bladder (contraction, necrosis, fistula, ureteric stricture or haemorrhage) UAEs. ResultsWe identified 73 men with a mean age of 73 years. Of these, 44 (60%) received combined therapy, consisting of RP + EBRT (n = 19), HDR brachytherapy + EBRT (n = 19), LDR brachytherapy + EBRT (n = 5), and other combined RT (n = 1). Twenty-nine (40%) patients had monotherapy consisting of EBRT (n = 4), HDR brachytherapy (n = 11), LDR brachytherapy (n = 12), or proton beam therapy (n = 2). UAEs were isolated to the bladder in six men (8%), the outlet in 52 men (71%), and to both in 15 men (21%). UAE management included: conservative in 21 (29%), indwelling catheters in 12 (16%), reconstructive in 19 (26%), and urinary diversion (UD) in 23 men (32%). Reconstruction included: ureteric (n = 4), recto-urethral fistula repair (n = 2), and posterior urethroplasty (n =13), of which 14/16 surgeries (88%) with follow-up >90 days were successful. ConclusionsAlthough the incidence of RTOG grade 4 UAEs after PCa radiation treatment is not well defined, their associated morbidity is significant, and approximately one third of patients with these high-grade complications require UD. Conversely, only about a quarter of patients can be managed with conservative strategies or local surgeries. Reconstruction is successful in selected patients.

Radiotherapy‐related complications presenting to a urology department: a more common problem than previously thought?

“…These findings are in keeping with data from Mayer et al. , who noted similarly that patients with complex radiotherapy complications required urinary diversion. Strictures were the next most common complication; ureteric strictures were more common than urethral.…”

“…Frequently these complications required surgical intervention, and an operative rate of 67% was noted. Similar surgical intervention rates for patients with urinary adverse events after radiotherapy for prostate cancer have been reported .…”

Urinary Diversion for Incontinence and Voiding Dysfunction in Cancer Survivors: a Critical Review of the Literature

“…From the study by Mayer et al, men who underwent UD were noted to have the most significant complications (nine in total) as well including three deaths, two Clavien-Dindo grade 4 complications and eight readmissions within 6 weeks of UD. The authors emphasize that UD is an option of last resort, as it is not without reported risk of complications (39%) and death (13%) [9].…”

“…Mayer et al reported on urinary adverse sequelae of radiotherapy for treatment of prostate cancer [9]. In a retrospective review, they report the adverse urinary events of 73 men with prostate cancer treated with various radiation therapies.…”