CHICAGO, IL, USA (UroToday.com) - Dr. Timothy Boone presented on the obstructed bladder following radiation therapy for prostate cancer. He noted that most men develop urinary retention after external beam radiation therapy (EBRT), after brachytherapy with or without EBRT, and in those who have a combination of EBRT and a RRP. Some of the later develop refractory BNCs. Dr. Boone felt the experience of the person doing brachytherapy affects the incidence of acute urinary retention (AUR) which may be the results of a “learning curve.” He quoted 2 authors who have published their AUR numbers: Keyes, et.al.1 reported overall AUR (n=805) was 12.7%, and prolonged urinary obstruction incidence (> 20 days) was 5%.
He quoted Dr. Landis from the University of Washington who felt that the risk of UR and long-term urinary dysfunction is probably multifactorial and only crudely defined by known clinical variables. But overall, 30 – 50% of men develop “acute” retention symptoms. Bladder outlet obstruction (BOO) beyond 3 months occurs in 2-15% of men who require TURP/dilation.2
Dr. Boone reviewed two large retrospective studies of brachytherapy:
Kollmeier, et al.3, reported on 38 out of 2,050 men (2%) who underwent minimal (channel) TURP due to urinary symptoms or retention.
Chen, et al.4, reported on Medicare claims data from 1991- 1996 that included 5,621 men and indicated that 30% developed BOO within 2 years, with 10% requiring surgery.
Risk factors for developing symptomatic UR following brachytherapy have been identified by Keyes et al and include: older age, use of androgen suppression, large prostate volume (>40 -50 cc), high IPSS (>16) pre-brachy, EBRT before or after, previous TURP and PVR<>3 months) include permanent Urolume Wallstent and there are dissolvable PGA stents for temporary use. Another option is the Mitrofanoff to native bladder or diversion. Dr. Boone concluded that most early BOO occurs following brachytherapy with or without XBRT and that prevention is probably the best medicine. Limited TURP can be successful in many cases but these men have a higher risk of UI (up to 18%) and a higher risk of “non-healing” urothelium, strictures and dystrophic calcification with ongoing necrosis. And there is little published data on the use of Stents post-brachytherapy. But men with PPI and BNC can be successfully managed with a stent and AUS if carefully selected.
References:
1. Keyes M, Schellenberg D, Moravan V, McKenzie M, Agranovich A, Pickles T, Wu J, Liu M, Bucci J, Morris WJ. Decline in urinary retention incidence in 805 patients after prostate brachytherapy: the effect of learning curve? Int J Radiat Oncol Biol Phys. 2006 Mar 1;64(3):825-34.
2. Landis, D.,Wallner K, Locke J, Ellis W, Russell K, Cavanagh W, Blasko J. Late urinary function after prostate brachytherapy. Brachytherapy. 2002;1(1):21-6.
3. Kollmeier MA, Stock RG, Cesaretti J, Stone NN. Urinary morbidity and incontinence following transurethral resection of the prostate after brachytherapy. J Urol. 2005 Mar;173(3):808-12.
4. Chen AB, D'Amico AV, Neville BA, Earle CC. Patient and treatment factors associated with complications after prostate brachytherapy. J Clin Oncol. 2006 Nov 20;24(33):5298-304.
5. Hu K, Wallner K. Urinary incontinence in patients who have a TURP/TUIP following prostate brachytherapy. Int J Radiat Oncol Biol Phys. 1998 Mar 1;40(4):783-6.
6. Kollmeier MA, Stock RG, Cesaretti J, Stone NN. Urinary morbidity and incontinence following transurethral resection of the prostate after brachytherapy. J Urol. 2005 Mar;173(3):808-12
7. Terk MD, Stock RG, Stone NN. Identification of patients at increased risk for prolonged urinary retention following radioactive seed implantation of the prostate. J Urol. 1998, Oct;160(4):1379-82.
8. Blaivas JG, Weiss JP, Jones M. The pathophysiology of lower urinary tract symptoms after brachytherapy for prostate cancer. BJU Int. 2006 Dec;98(6):1233-7
Presented by Timothy Boone, MD at the Annual Meeting of the American Urological Association (AUA) - April 25 - 30, 2009 - McCormick Place Convention Center - Chicago, Illinois, USA.
source: www.urotoday.com
