Urinary fistulas following external radiation or permanent brachytherapy for the treatment of prostate cancer

PURPOSE: Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. MATERIALS AND METHODS: Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. RESULTS: A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. CONCLUSIONS: Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.     

Simple clinical examination predicts complexity of perianal fistula

OBJECTIVE: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.     

Adjuvant postoperative radiation therapy for Dukes C adenocarcinoma of the rectum.

This study was designed to explore the effects of adjuvant postoperative radiation therapy on the course and survival of patients with Dukes C adenocarcinoma of the rectum. Moderate dose radiotherapy was offered to 64 patients. Twenty-four accepted and were treated, while the remainder refused. With a mean follow-up of 32.3 months, the overall survival rate was 63% (40/64) and the mean disease-free survival rate at the time of this report was 45%. The following variables were analyzed separately: operative procedure, distance of the tumor from the anal verge, tumor size, and transmural, vascular, lymphatic and perineural invasion of tumor. The most significant differences between irradiated and non-irradiated patients were found in the group of patients whose lesions were 6 cm or less from the anal verge. Of the 19 such patients with an average follow-up of 36.4 months, ten patients were irradiated and nine were not irradiated. The irradiated group had a 90% (9/10) survival rate and 70% (7/10) of them were disease free; the non-irradiated group had a 44% (4/9) survival rate and 22% (2/9) of them disease free. It is concluded that patients with adenocarcinoma of the rectum metastatic to lymph nodes, whose lesions' lower border is measured 6 cm or less from the anal verge, benefit significantly from adjuvant postoperative radiotherapy.     

Rectourinary fistula repair using the Latzko technique

PURPOSE: We report our experience with the Latzko technique for rectourinary fistula repair after radical retropubic prostatectomy and cystoprostatectomy. MATERIALS AND METHODS: We performed 7 fistula repairs in 6 patients. The 1-stage procedure was based on a technique for vesicovaginal fistula closure with denudation of the rectal mucosa and multilayer closure of the fistulous tract. RESULTS: Closure was successful in all patients, although 1 had to undergo the procedure twice. There were no postoperative complications. CONCLUSIONS: The Latzko procedure is effective for rectourinary fistula repair and associated with minimal morbidity.     

Transanal Repair of Rectourethral Fistula After a Radical Retropubic Prostatectomy: Report of a Case

Rectourethral fistula occurred in a 64-year-old man after a radical prostatectomy. Despite conservative treatment the fistula did not close spontaneously. Eleven months after the original prostatectomy, an operation was performed. We chose the Latzko technique with slight modifications as follows. The patient was placed in the prone jackknife position. The fistula was found at a site about 6.0 cm from the anal verge. An elliptical area of rectal mucosa was incised about 1.5 cm from the fistulous orifice and subsequently the rectal mucosa was denuded. The submucosa was dissected above the fistula about 2.0 cm from the edge of the incision. The fistula was then closed with one layer of side-by-side absorbable 2-0 polyglactin sutures. The dissected rectal mucosal flap was brought down over the fistula and sutured in one layer to the distal edge of the rectal muscularis propria through the mucosa with 3-0 polyglactin sutures. On postoperative day 21 a retrograde urethrogram was made and it showed no leakage of urine via the rectum. This procedure is a simple, effective, and minimally morbid technique for the repair of rectourethral fistula after a radical prostatectomy, although it is only useful for the treatment of low rectourethral fistulas. Received: March 8, 2001 / Accepted: September 11, 2001     

Quality of life outcomes after brachytherapy for early stage prostate cancer

PURPOSE: We compare general and disease specific health related quality of life in men undergoing brachytherapy for early stage prostate cancer to those undergoing radical prostatectomy and age matched healthy controls. MATERIALS AND METHODS: Cohorts consisted of 48 men treated with brachytherapy with and without pretreatment external beam radiation therapy (brachytherapy group), 74 who underwent radical prostatectomy (prostatectomy group) and age matched healthy controls from the literature. The RAND 36-item general health survey, University of California Los Angeles Prostate Cancer Index, American Urological Association symptom index, validated Cancer Interference with Life and Family Scales, and sociodemographic and co-morbidity questionnaires were completed 3 to 17 months after treatment. RESULTS: General health related quality of life did not differ greatly among the 3 groups. Urinary function (leakage) was worse in the brachytherapy group than in controls but better than in the prostatectomy group. Brachytherapy group patients had more irritative urinary symptoms and worse bowel function than controls. Sexual function and bother were worse in prostatectomy and brachytherapy groups than in healthy controls. Physical function, bodily pain, urinary function, and bother and American Urological Association symptom index scores improved with time after brachytherapy. Patients who underwent brachytherapy after external beam radiation performed worse in all general and disease specific health related quality of life domains compared to those who did not undergo pretreatment radiation therapy. CONCLUSIONS: At an average of 7.5 months after treatment the general health related quality of life of patients undergoing brachytherapy with and without pretreatment external beam radiation was similar to age matched controls, although urinary, bowel and sexual problems were reported. These problems appeared to improve during the first year after treatment. Much of the impairment in disease specific health related quality of life among patients undergoing brachytherapy may be attributed to pretreatment radiation.     

The development of erectile dysfunction in men treated for prostate cancer

PURPOSE: Erectile dysfunction is a common side effect in men treated for prostate cancer. Previously published studies document the incidence of erectile dysfunction in men treated for prostate cancer to be between 20% and 88%. To our knowledge a prospective evaluation focused on the development of erectile dysfunction in men treated for prostate cancer has not elucidated components of its chronology or risk factors. MATERIALS AND METHODS: A centralized prospective database of 2,956 patients diagnosed with prostate cancer at a single institution was studied in regard to pretreatment and posttreatment erectile dysfunction. Of these 2,956 patients 802 had sufficient information regarding erectile function and comprise our study population. Factors analyzed in regard to treatment and erectile dysfunction include treatment modality, that is radical prostatectomy, external beam radiation therapy and watchful waiting, and ethnicity, patient age, clinical stage and tumor histological grade. RESULTS: No significant difference was noted in the posttreatment erectile function between patients treated with radical prostatectomy or external beam radiation (10% versus 15%). Patients selecting watchful waiting had the lowest risk of erectile dysfunction. Clinical stage and race were significant predictors for the development of erectile dysfunction in the watchful waiting and external beam radiation treatment groups. CONCLUSIONS: Erectile dysfunction develops in greater than 80% of patients treated for prostate cancer. External beam radiation has the same risk for erectile dysfunction as radical prostatectomy.     

Preoperative radiation therapy and its effects on outcomes in microsurgical head and neck reconstruction.

OBJECTIVE: Preoperative radiation therapy is considered a significant factor in head and neck reconstruction. STUDY AND DESIGN AND SETTING: In our consecutive series of 114 patients, 44 patients had prior head and neck irradiation. The 2 groups were compared on the basis of age, ischemic time, and flap size and were found not to be statistically different. The average ischemic time for the irradiated group was 94.1 minutes, and the average was 102.8 minutes for the nonirradiated group. The average flap size for the irradiated group was 69.5 cm 2 and was 72.0 cm 2 for the nonirradiated group. RESULTS: Using a single-factor analysis of variance, the 2 groups did not differ statistically. The overall major flap complication rate for both irradiated and nonirradiated groups was approximately 10%. CONCLUSION: Microvascular reconstruction was accomplished in both irradiated and nonirradiated head and neck patients, with a 99% total flap survival rate and a 10% major flap complication rate.     

Morbidity and mortality of local failure after definitive therapy for prostate cancer

We reviewed our experience with morbidity and mortality associated with clinical local failure after definitive therapy for adenocarcinoma of the prostate by interstitial 125iodine implantation, external beam radiation therapy or radical prostatectomy. Morbid complications included unilateral ureteral obstruction; bladder obstruction and/or incontinence requiring treatment by transurethral resection, or placement of a urethral or suprapubic catheter; hematuria requiring intervention for clot evacuation or fulguration, and perineal and/or pelvic pain. Lethal complications included bilateral ureteral obstruction or bowel obstruction. We treated 108 patients with 125iodine, 178 with external beam radiotherapy and 67 with radical prostatectomy. Clinical local failure occurred in 26 per cent of the 125iodine, 17 per cent of the external beam radiotherapy and 12 per cent of the radical prostatectomy groups. The total incidence of local failure with 125iodine was statistically higher than for radical prostatectomy. Stage C and poorly differentiated tumors were associated with a statistically higher incidence of local failure compared to lower stage and grade tumors. However, within each stage and grade there was no significant difference in local failure between treatment modalities. There was negligible morbidity or mortality secondary to local failure associated with stage A2, stage B1 or well differentiated tumors regardless of treatment modality. There was no difference in the morbidity and mortality between treatment modalities for stage C or poorly differentiated tumors. However, for stage B2 or moderately differentiated tumors treated by 125iodine implantation there was a statistically greater incidence of morbidity and mortality than that associated with external beam radiotherapy and radical prostatectomy. Our observations with regard to selection of primary monotherapy options that provide local tumor control are as follows. Stage A2, stage B1 or well differentiated tumors can be well controlled by all 3 treatment modalities. 125Iodine is associated with local failure-related morbidity and mortality for stage B2 or moderately differentiated tumors, which are statistically higher than for external beam radiotherapy and radical prostatectomy, and therefore, these latter are the preferred treatment. Radical prostatectomy and 125iodine for stage C tumors are associated with a trend to higher local failure, and related morbidity and mortality than is external beam radiotherapy. However, longer followup of the external beam radiotherapy series is necessary to confirm this observation.     

Quality of life after treatment for localized prostate cancer: differences based on treatment modality

PURPOSE: Brachytherapy with 103palladium (103Pd) is an increasingly administered treatment modality for localized prostate cancer. We compared general and disease specific health related quality of life after 103Pd treatment, radical prostatectomy and external beam radiation therapy given during the same time frame. MATERIALS AND METHODS: We performed a retrospective cross-sectional survey study of patients treated at a single community medical center between 1995 and 1999. We mailed 5 validated health related quality of life survey instruments to 269, 142 and 222 men who underwent radical prostatectomy, 103Pd treatment and external beam radiation therapy, respectively, with a response rate of greater than 80% in all groups. RESULTS: General health related quality of life assessed by the SF-36 showed the same scores in patients who underwent prostatectomy and 103Pd treatment. The University of California-Los Angeles Prostate Cancer Index was used to assess bowel, urinary and sexual function/bothersomeness. External beam radiation therapy reported was associated with worse bowel function and greater bowel bothersomeness. Prostatectomy was associated with worse urinary function compared to 103Pd and external beam radiation therapy. Prostatectomy was associated with worse sexual function than 103Pd or external beam radiation therapy, although nerve sparing surgery and erectile aids minimized the difference. American Urological Association symptom scores were initially higher for 103Pd but became equal to those in the other groups in patients treated greater than 12 months from survey time. Disease-free men who underwent prostatectomy and 103Pd brachytherapy were equally confident that cancer would not recur in the future. Satisfaction rates were equivalent and biochemical failure significantly decreased satisfaction in all groups. CONCLUSIONS: While general health related quality of life was mostly unaffected by the 3 most common treatments for prostate cancer, there were differences in bowel, urinary and sexual function. This information may aid patients in the decision making process.     

Anal and perianal malignancies

Perianal carcinomas must be segregated from anal canal carcinomas, which occur above the anal verge. Perianal malignancies are managed as are skin malignancies elsewhere on the body. Squamous cell carcinomas of the anal canal less than 2 cm in diameter may be treated by local excision. Other epidermoid anal canal carcinomas are best treated with either radiation therapy or a combination of chemotherapy and radiation followed by abdominoperineal resection for those patients with residual tumor on biopsy.     

Localized prostate cancer. Local treatment and what place for lymphadenectomy

The pretreatment PSA level, the Gleason score, the presence of lymph-node metastases, the status of surgical positive margins are poor pathological risk factors for patients who have a pathologic stage T3 prostate cancer. The increase in PSA level during the year prior to diagnostic is associated with the risk of death due to prostate cancer following radical prostatectomy or external beam radiation therapy. The assessment of Locoregional extension is indicated for such patients. The extended pelvic lymphadenectomy remains the most accurate procedure for a correct staging of the detection of nodal involvement in these patients with high-risk localized prostate cancer. For such patients with a high-risk of progression and, whose the life expectancy is greater than 10 years, treatment must be a combined modality therapy since radical prostatectomy alone correlates with a poor clinical outcome. Adjuvant hormonal therapy following local curative treatment by prostatectomy (or radiotherapy) needs to be often considered. Collegial decision-making is by far the most appropriate setting for the discussion among medical specialists of these complex clinical cases for patients often having associated medical conditions and whose adjuvant treatment will have a significant impact of their future quality of life.     

Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule

OBJECTIVE: To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge. SUMMARY BACKGROUND DATA: Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection. METHODS: From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy. RESULTS: Ninety-two patients with a tumor at 3 (range 1.5-4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively. CONCLUSIONS: The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection.     

Indications, techniques and outcomes of high-intensity focused ultrasound (HIFU) for the treatment of localized prostate cancer

High-intensity focused ultrasound (HIFU) is a minimally invasive alternative for patients with localized prostate cancer, not suitable for radical prostatectomy because of a life expectancy less than 10 years or because of major co-morbidities precluding surgery. HIFU can be performed in patients with LUTS (associated TURP) or with a previous history of BPH surgery. HIFU is repeatable after the initial procedure if a recurrent cancer is diagnosed on control biopsies. Furthermore, this therapy is a viable option for patients with a local relapse after external beam radiation therapy: oncologic efficacy is conversely related to the initial prostate cancer stage before radiation therapy.     

Comparing prostate specific antigen outcomes after different types of radiotherapy management of clinically localized prostate cancer highlights the importance of controlling for established prognostic factors

PURPOSE: We evaluated the impact that the composition of prognostic factors in a patient cohort may have on prostate specific antigen (PSA) outcome following external beam radiation therapy for clinically localized prostate cancer. MATERIALS AND METHODS: The distribution of PSA, biopsy Gleason score and American Joint Committee on Cancer (AJCC) T stage in men with prostate cancer treated with interstitial plus external beam radiation therapy was used to select a matched cohort who underwent 3-dimensional (D) conformal external beam radiation therapy. We compared PSA outcomes after 3-D conformal external beam radiation therapy in the overall and matched cohorts of 766 and 570 patients, respectively. RESULTS: Men treated with interstitial plus external beam radiation therapy had a significantly lower rate of PSA greater than 10 to 20 (p = 0. 02) and greater than 20 ng./ml. (p <0.0001), biopsy Gleason score 7 (p = 0.02) and 8 to 10 (p <0.0001), and AJCC stage T2c disease (p <0. 0001). Likewise, these men also had a significantly higher rate of PSA greater than 4 to 10 ng./ml. (p <0.0001), biopsy Gleason score 5 to 6 (p = 0.0001) and AJCC stage T1 disease (p <0.0001) than those who underwent 3-D conformal external beam radiation therapy. The 5-year estimate of PSA failure-free survival after 3-D conformal external beam radiation therapy was 45% versus 67% (p = 0.0007) for all 766 consecutively treated patients and the matched cohort of 570, respectively. CONCLUSIONS: The composition of prognostic factors in a patient cohort may impact PSA outcome. Therefore, controlling for established prognostic factors is essential when comparing PSA outcome after different forms of radiotherapy for adenocarcinoma of the prostate.     

Predictors of secondary cancer treatment in patients receiving local therapy for prostate cancer: data from cancer of the prostate strategic urologic research endeavor

PURPOSE: Secondary cancer treatment is common after definitive local therapy for prostate cancer and it may be an indicator of the efficacy and cost of primary local treatment. We determined predictors of secondary cancer treatment in patients initially treated with radical prostatectomy or external beam radiation. MATERIALS AND METHODS: We examined 2,336 patients in Cancer of the Prostate Strategic Urologic Research Endeavor, a longitudinal registry of patients with prostate cancer, who underwent initial treatment with radical prostatectomy (1,744) or external beam radiation (592). Patients had at least 1 month of followup and all pretreatment information was available. The percent of patients receiving secondary cancer treatment, time to secondary treatment and type of secondary treatment delivered was determined. Multivariate analysis was done to determine independent predictors of secondary cancer treatment. In patients initially treated with prostatectomy a similar analysis was performed to identify predictors of receiving androgen deprivation versus radiation. RESULTS: A total of 590 patients (25%) received secondary cancer treatment, including prostatectomy in 391 (22%) and radiation in 199 (34%). Secondary cancer treatment was equally divided between radiation and androgen deprivation in 52% and 47%, respectively, of those initially treated with prostatectomy, while 92% initially treated with radiation received androgen deprivation. Predictors of any secondary treatment included patient age, biopsy Gleason score and prostate specific antigen at diagnosis. There was a trend toward increased secondary treatment more than 6 months after local therapy in patients initially treated with radiation. Increased age and lymph node metastases were independent predictors of receiving androgen deprivation after prostatectomy, while there was increased use of radiation in patients with positive surgical margins or extracapsular disease extension. CONCLUSIONS: Secondary treatment differs in patients initially treated with radical prostatectomy and radiation. Pretreatment factors can be used to counsel patients regarding the likelihood of secondary treatment, while age and prostatectomy results appear to determine the type of secondary treatment in those initially treated with prostatectomy.     

Sphincter-saving surgery in low rectal cancer

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.     

Acquired rectourethral fistula: case report

Rectourethral fistulas are an uncommon complication of urinary or rectal surgery, trauma, inflammatory disease, radiation therapy for prostate cancer; they represent an unique challenge for the surgeon. Although closure can occure spontaneously, most cases of acquired rectourethral fistula need surgical repair. Despite a century of surgical experience, no single approach has been universally accepted. We report a case of a rectourethral fistula occurred in a 73 year-old man after a radical retropubic prostatectomy and external beam irradiation for prostate cancer, successfully treated with perineal approach.     

An assessment of quality of life following radical prostatectomy, high dose external beam radiation therapy and brachytherapy iodine implantation as monotherapies for localized prostate cancer

PURPOSE: Monotherapy with radical prostatectomy, high dose external beam radiotherapy or a (125)I implant is reported to produce equivalent outcomes. We assessed the health related quality of life associated with these 3 treatment approaches. MATERIALS AND METHODS: Extended Prostate Index Composite surveys were mailed to all 960 patients treated with a (125)I implant, high dose external beam radiotherapy or radical prostatectomy with or without hormonal therapy at our institution from 1998 to 2000. A total of 625 patients (65%) completed the surveys. Nerve sparing radical prostatectomy was performed when appropriate. The (125)I implant consisted of 145 Gy and high dose external beam radiotherapy consisted of 78 Gy. For urinary, rectal and sexual domains mean scores were calculated, compared by treatment modality and compared to normative values. RESULTS: A total of 234 patients with radical prostatectomy, 135 with external beam radiotherapy and 74 with a (125)I implant were treated with a monotherapy approach. Median age was 61 years in the radical prostatectomy group, 68 years in the high dose external beam radiotherapy group and 64 years in the (125)I implant group (p <0.001). Of the patients 97% [corrected] had cT1-2 disease and Gleason score 7 or less [corrected] Median time from treatment was 4.0 years for radical prostatectomy, 4.7 years for high dose external beam radiotherapy and 3.5 years for (125)I implantation. Radiation caused significantly worse bowel bother and bowel function than radical prostatectomy (p < or =0.018). Patients with high dose external beam radiotherapy had significantly better urinary function than patients with radical prostatectomy (p <0.001). While patients with radical prostatectomy had significantly worse urinary incontinence than those with a (125)I implant or high dose external beam radiotherapy (p <0.0001), patients with a (125)I implant had more urinary irritation than those with high dose external beam radiotherapy and radical prostatectomy (p <0.01 and <0.0001, respectively). Patients with a (125)I implant had significantly better sexual function than those with high dose external beam radiotherapy and radical prostatectomy (p = 0.01 and 0.0003, respectively). CONCLUSIONS: Of patients with prostate cancer treated with a monotherapy approach we noted better urinary continence in those who underwent radiation based therapies, and better bowel function and less urinary irritation in those who underwent surgery. Sexual function was impaired across all monotherapies but higher scores were seen in men who selected brachytherapy.