To describe the management of grade 4 Radiation Therapy Oncology Group (RTOG) urinary adverse events (UAEs) after radiotherapy (RT) for prostate cancer (PCa). We hypothesized grade 4 UAEs often require complex surgical management and subject patients to significant morbidity.
A single-center retrospective review, over a 6-year period (2010-2015), identified men with RTOG grade 4 UAEs after RT for PCa. RT was classified as combined modality therapy (radical prostatectomy (RP) followed by external beam radiotherapy (EBRT), EBRT + low-dose brachytherapy (LDR), EBRT + high-dose brachytherapy (HDR), or other combinations of RT) or single modality RT. UAEs were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, or recto-urethral fistula) or bladder (contraction, necrosis, fistula, ureteral stricture, or hemorrhage).
We identified 73 men with a mean age of 73 years. Forty-four (60%) had combined modality therapy, consisting of RP + EBRT (19), high dose rate brachytherapy (HDR) + EBRT (19), low dose rate brachytherapy (LDR) + EBRT (5), and other combined modality RT (2). Twenty-nine (40%) patients had single modality therapy consisting of EBRT (4), HDR (11), LDR (12), or proton beam (2). UAEs were isolated to the bladder in 6 (8%), the outlet in 52 (71%), and both in 15 (21%). UAE management included: conservative in 21 (29%), indwelling catheters in 12 (16%), reconstructive in 19 (26%), and urinary diversion in 23 (32%). Reconstruction included: ureteral (4), recto-urethral fistula repair (2), and posterior urethroplasty (13), of which 14/16 (88%) surgeries with follow-up >90 days were successful.
Although the incidence of RTOG grade 4 UAEs after PCa radiation treatment is not well defined, their morbidity is significant, and approximately one third of patients with these high-grade complications require urinary diversion. Conversely only about a quarter of patients can be managed with conservative strategies or local surgeries. Reconstruction is successful in selected patients. This article is protected by copyright. All rights reserved.