Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma

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.

OBJECTIVE

To 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 METHODS

In 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.

RESULTS

All 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.

CONCLUSIONS

Brachytherapy 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.