Management of Voiding Dysfunction after Prostate Radiotherapy

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1 Management of Voiding Dysfunction after Prostate Radiotherapy Up to Date Symposium on Uro-Oncology December 7, 2012 Belo Horizonte, Brazil Jaspreet S. Sandhu, MD Department of Surgery/Urology Memorial Sloan-Kettering Cancer Center

2 Outline Natural History of Urinary Function Recovery after RT Voiding dysfunction after radiation therapy Etiology Management Late Effects

3 Outcomes: Expanded Prostate Cancer Index Composite (EPIC-26)

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5 Etiology Multiple preoperative factors implicated for urinary morbidity after prostate radiotherapy IPSS (8 or greater worse) PVR (100 mls or greater) Peak Flow Rate (10 ml/sec or less) Prostate Volume (40 ml or more) BOO on urodynamics Intraoperative technique (dose, etc.) Gelblum, et al. Urinary Morbidity following ultrasound-guided transperineal prostate seed implantation, IJROBP 1999 Beekman, et al. Selecting patients with preoperative Post Void Residual Urine less than 100 ml may favorably influence brachytherapy-related urinary morbidity, Urology 2005 Martens, et al. Relationship of the International Prostate Symptom score with urinary flow studies, and catheterization rates following 125I prostate brachytherapy. Brachytherapy Choo, et al. Urodynamic changes at 18 months post-therapy in patients treated with external beam radiotherapy for prostate carcinoma. IJROBP 2002

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7 Urodynamics Post-Brachytherapy Symptoms: Weak Stream Urgency/frequency Nocturia Dx: Bladder Outlet Obstruction Detrusor Overactivity Rec: Cystoscopy Alpha Blockers +/- TURP

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10 Medical Therapy Alpha blockers mainstay Role for anticholinergics in select patients Injection of biological agents (won t discuss)

11 Flomax

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13 Trospium 69 patients treated for irritative symptoms (frequency, urgency, nocturia) Resolution defined as IPSS within 2 of baseline Median time to start of trospium 23.4 months 80% resolution

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15 Incidence of Urinary Retention after Brachytherapy Bimodal Distribution Immediately after implantation Delayed presentation Incidence Up to 20% Learning curve associated with decrease from 17% - 6% Prevention IPSS Prostate size Flow rate/post void residual?pre-procedure urodynamic parameters Williams et al, Radiother Oncol, 2004 Keyes, et al, IJROBP, 2006

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17 Urinary Retention post Radiotherapy Edema Clot Retention Infection Urinary Calculi/Foreign Body Bladder Outlet Obstruction Detrusor Underactivity

18 Infection Can occur anytime, but likely within weeks to months of implant Later presentation often with sudden onset of increases LUTS Definitive diagnosis difficult Treatment Long term course of antibiotics (Fluoroquinolones have excellent prostatic penetration) Possible suprapubic tube if no resolution in a few days Possible transrectal ultrasound to rule out abscess

19 Post Radiation TURP Stress urinary incontinence as high as 70% Rate reduced to 12% with appropriate patient selection Urodynamically obstructed New onset obstruction without previous voiding symptoms Minimize fulgaration while resecting posterior (and anterior) prostate to prevent fistula Usually dramatic improvement in voiding symptoms and urge incontinence Secondary TURPs not recommended Higher rate of rectal fistulas and incontinence

20 SEER/Medicare Analysis 5621 men between with 2 years of follow-up Urinary Morbidity 33.8% Invasive Procedures 10.3% Factors associated: Older age Non-white race Lower income External beam RT Androgen depravation Later year of brachytherapy Charlson co-morbidity

21 Kollmeier 38 patients treated with TURP Retention or obstructive LUTS Median time from RT 11 months 18% incontinent

22 Bladder Outlet Obstruction Usually occurs late unless preexisting obstruction Stricture versus prostatic obstruction Diagnosed by urodynamic testing in conjunction with cystoscopy Treatment Internal uretherotomy (stricture disease) Transurethral resection of the prostate (TURP) UroLume Endoprosthesis Clean intermittent catheterization (CIC) Suprapubic tube (SPT) Urinary diversion (UD)

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24 Late Effects Urinary Fistula Secondary Malignancy Sarcoma Bladder cancer Rectal cancer Radio-resistant prostate cancer

25 Urinary Fistulae Often due to Endoscopic manipulation of radiated tissue Rectal fistula secondary to colonoscopic or cystoscopic intervention Pubovesical fistula/sinus

26 Fistula - Angermeier

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33 Pubo-Vesical Fistulae Likely secondary to aggressive treatment of AS Presents with subrabupic pain/osteitis +/- UTIs Usually after RT Conservative measures include long course of antibiotics with foley/pcns Possible role of HBO Only definitive treatment to prevent recurrent UTI s is cystectomy/diversion

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39 Salvage RP 50% rate of urinary incontinence Suggestion that it is lower in recent series (Learning curve) Attempts being made to decrease this rate 20-40% rate of anastomotic stricture 1-5% rate of recto-vesical fistula formation

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41 Conclusion Diverse etiologies for voiding dysfunction after prostate cancer treatment Important to know natural history Diverse voiding dysfunction after radiotherapy Medical (alpha blockade +/- anticholinergics) Surgical (particularly for BOO) Don t forget late effects

42 Thank You