Prostatourethral-rectal fistula after prostate brachytherapy

Theodorescu, Dan; Gillenwater, Jay Y.; Koutrouvelis, Panos G.

doi:10.1002/1097-0142(20001115)89:10<2085::aid-cncr8>3.0.co;2-q

Cited by 154 publications

(68 citation statements)

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“…16 To our knowledge, the incidence of radiation proctitis after brachytherapy in the current series is higher than in previous reports. [3][4][5][6][12][13][14][15] Moreover, the incidence of rectal symptoms for which colonoscopy was performed more than doubled after combination therapy. It is important to note that all the significant rectal complications requiring colostomy or ileostomy and colectomy were reported to occur in 4 of the 61 patients undergoing combination therapy (6.6%).…”

Section: Discussionmentioning

confidence: 99%

“…Most reports cite an incidence of 0 -1% for brachytherapy, although it has been reported to increase to as high as 2.9% with combination therapy, and up to 8.8% in patients un-dergoing salvage brachytherapy after prior "definitive" EBRT. 6 Blasko et al reported an incidence of 0.8% in 231 patients treated with combination therapy and followed for a median of 58 months. 18 The reason that more complications appear to occur with combination therapy is likely multifactorial.…”

Section: Discussionmentioning

confidence: 99%

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Urinary and rectal complications of contemporary permanent transperineal brachytherapy for prostate carcinoma with or without external beam radiation therapy

Sarosdy

2004

Cancer

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BACKGROUND Prostate brachytherapy is increasingly used to treat prostate carcinoma, alone or combined (combination therapy) with external beam radiation therapy (EBRT). This report cites the frequency and nature of urinary and rectal complications requiring unplanned interventions after contemporary brachytherapy with or without EBRT. METHODS A total of 177 consecutive patients underwent either brachytherapy (100 patients [56.5%]) or combination therapy (77 patients [43.5%]) for clinical T1‐2 prostate carcinoma between July 1998 and July 2000. All the patients were analyzed with regard to disease characteristics, treatment details, and complications requiring unplanned interventions in up to 48 months of follow‐up. RESULTS Catheter drainage for urinary retention was required for a median of 55 days (range, 3–330 days) in 36 patients (20%), including 24% after brachytherapy and 16% after combination therapy. Transurethral resection of the prostate (TURP) was performed at a median of 12 months (range, 8–18 months) after implantation in 5% of patients after brachytherapy and 14.5% of patients after combination therapy (P = 0.029). Colonoscopy with or without fulguration for rectal bleeding was performed in 37 of 158 patients (97 in the brachytherapy group and 61 in the combination therapy group) (23.4%) at a median of 17 months (range, 4–45 months), including 15 patients (15.5%) after brachytherapy and 22 patients (36%) after combination therapy (P = 0.002). Combination therapy resulted in fecal diversion in 6.6% of patients (P = 0.021), urinary diversion in 3.2% of patients (P = 0.148), and clean intermittent self‐catheterization for recurrent stricture after multiple TURPs in 4.9% of patients (P = 0.055), none of which occurred after brachytherapy. Overall, 20.6% of patients underwent TURP or colonoscopy after brachytherapy, whereas 44.2% underwent those or more extensive unplanned procedures after combination therapy (P = 0.001). CONCLUSIONS Complications requiring unplanned procedures may occur after brachytherapy, and may be increased significantly after brachytherapy combined with EBRT. These data reinforce the concept that quality assurance and technique are important in prostate brachytherapy, but, even when these are in place, complications can occur, especially when EBRT is added to brachytherapy. Cancer 2004. © 2004 American Cancer Society.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Urinary and rectal complications of contemporary permanent transperineal brachytherapy for prostate carcinoma with or without external beam radiation therapy

Sarosdy

2004

Cancer

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“…In general, morbidity has been reported to be mild and short-term [3]; classic complications, e.g. urinary incontinence and erectile dysfunction, are well defined [4,5].…”

Section: Discussionmentioning

confidence: 99%

Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma

et al. 2003

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Once again, there have been a significant number of papers on prostate cancer submitted and accepted, and this is reflected in that six of the nine papers published in this section this month relate to this disease. Many aspects of the condition are discussed. Readers may be interested learn of the severe complications associated with brachytherapy which the authors from Miami have described, and how they dealt with them. This type of therapy will continue to be reported in this journal, with several comments appearing in subsequent editions.Two papers appear on favourite topics in bladder cancer; what we can expect from T1G3 tumours, by authors from France, and the morbidity associated with extended lymphadenectomy, by authors from Austria and Italy. Finally, the authors from Paris with very extensive experience in laparoscopy describe this technique in the treatment of T1 renal cancer.OBJECTIVETo report a retrospective chart review of patients who developed recto‐urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer.PATIENTS AND METHODSIn the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60–81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York‐Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization.RESULTSAll six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York‐Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty.CONCLUSIONSBrachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York‐Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure.

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“…Theodorescu et al [14] also found supplemental external beam radiation to be associated with higher rates of prostatourethral-rectal fistula. These patients should be considered at higher risk of rectal complications and warrant careful planning and implanting as well.…”

Section: Fig 4 Individual Data Points For Patients Inmentioning

confidence: 97%

Dosimetric and radiographic correlates to prostate brachytherapy‐related rectal complications

Han

Wallner

2001

Intl Journal of Cancer

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SUMMARY Despite rates of radiation proctitis reported in the 1% to 9% range in most series, there is little information regarding rectal morbidity and dosimetric parameters. Accordingly, we have analyzed computed tomography (CT)-based dosimetric parameters based on a series of patients with endoscopically proven radiation proctitis. Nine patients diagnosed with radiation proctitis on endoscopy were identified in a prior review of 160 consecutively treated patients at the University of Washington in 1997. For each proctitis patient, two patients with no rectal bleeding matched for prostate size, isotope, and dose were selected as controls. Axial CT images obtained 2 to 4 hour postoperatively were used for postimplant dosimetry. Dose volume histograms of the rectum, surface area of the outer rectal wall receiving ≥ 100% of the prescribed dose, maximum rectal dose, and length of rectum receiving ≥ 100% prescription were obtained. Preimplant CT scans were used to group patients into three categories based on the amount of apparent rectal contact with the prostate. All rectal dosimetric parameters were statistically different between patients with or without rectal bleeding. The mean surface area receiving at least 100% prescription dose was 3.1 cm 2 for the controls vs. 6.9 cm 2 for the rectal bleeders (P = 0.001). The volume of rectum receiving at least 100% of prescription dose was 0.6 cc for the controls vs. 2.5 cc for the bleeders (P = 0.00008). Patients with full prostate-rectal contact had significantly higher rectal dose parameters compared to those with partial or no rectal contact. All nine proctitis patients were in the full-rectal-contact group compared to only seven of 18 (39%) controls. This detailed dosimetric analysis shows higher rectal doses for patients with radiation proctitis, making it a potential method of identifying patients at higher risk for receiving excessive rectal doses based on the anatomic relationship between the rectum and prostate on CT scan. Published 2001 Wiley-Liss, Inc. †

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Prostatourethral-rectal fistula after prostate brachytherapy

Cited by 154 publications

References 30 publications

Urinary and rectal complications of contemporary permanent transperineal brachytherapy for prostate carcinoma with or without external beam radiation therapy

Urinary and rectal complications of contemporary permanent transperineal brachytherapy for prostate carcinoma with or without external beam radiation therapy

Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma

Dosimetric and radiographic correlates to prostate brachytherapy‐related rectal complications

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