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Asian Journal of Urology, 2024, 11(4): 633-641    doi: 10.1016/j.ajur.2023.01.006
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Genitourinary toxicity after pelvic radiation: Prospective review of complex urological presentations
Rowan V. Davidab*(),Asif Islama,John Millera,Michael E. O'Callaghanab,Arman A. Kahokehrab
aDepartment of Urology, Lyell McEwin Hospital, Elizabeth Vale, Adelaide, Australia
bCollege of Medicine and Public Health, Flinders University, Bedford Park South Australia, Adelaide, Australia
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Abstract: 

Objective: Recent randomised controlled trials underestimated the incidence of genitourinary (GU) complications occurring more than 5 years following pelvic radiotherapy. This study aimed to determine the burden of treatment at a single institution from late GU complications after pelvic radiotherapy.

Methods: A prospective study of all presentations for GU complications following pelvic radiotherapy at a tertiary urology department between November 2018 and November 2019 was performed. Subgroup analyses was performed on patients with prostate cancer (PCa) with late toxicity to compare patient demographics, radiotherapy, complications, and management factors.

Results: There were 117 hospital encounters involving 46 patients with a 56.4% repeat encounter rate. Patients with PCa were the predominant group (n=39, 84.8%). External beam radiotherapy was the most common treatment modality (n=41, 89.1%). The median time from radiotherapy to encounter was 8 (range 0-23) years. Radiation-induced haemorrhagic cystitis was the most common presentation (n=70, 59.8%). Forty-four (42.7%) encounters for GU toxicity were managed operatively and 33 (32.0%) involved a non-operative procedure. Nine patients required packed red cell transfusion, with a total of 154 units transfused. Patients with PCa who presented with late GU toxicity had higher median Radiotherapy Oncology Group grades (p=0.020), proportion of emergency admissions (p=0.047), and frequency of clot urinary retention (p<0.001).

Conclusion: There is a high burden of elective and emergency urology workload attributed to late pelvic radiation toxicity. Late GU toxicity occurring ≥5 years after radiotherapy is common and often more severe.
Key words:  Pelvic malignancy    Radiotherapy    Genitourinary toxicity    Hospitalisation    Secondary malignancy
收稿日期:  2022-07-21           接受日期:  2023-01-09      出版日期:  2024-10-20      发布日期:  2024-11-20      整期出版日期:  2024-10-20
引用本文:    
. [J]. Asian Journal of Urology, 2024, 11(4): 633-641.
Rowan V. David, Asif Islam, John Miller, Michael E. O'Callaghan, Arman A. Kahokehr. Genitourinary toxicity after pelvic radiation: Prospective review of complex urological presentations. Asian Journal of Urology, 2024, 11(4): 633-641.
链接本文:  
http://www.ajurology.com/CN/10.1016/j.ajur.2023.01.006  或          http://www.ajurology.com/CN/Y2024/V11/I4/633
Characteristic Overall, n=46 Time from radiotherapy
<5 years, n=15 ≥5 years, n=31 p-Valuea
Toxicityb 0.72c
Fistula 1 (2.2) 0 (0) 1 (3.2)
Haematuria 34 (73.9) 11 (73.3) 23 (74.2)
Incontinence 1 (2.2) 1 (6.7) 0 (0)
RASM 2 (4.3) 1 (6.7) 1 (3.2)
Retention 2 (4.3) 0 (0) 2 (6.5)
Stricture 6 (13.0) 2 (13.3) 4 (12.9)
Age, year <0.01d
Median (IQR) 71 (65-76) 76 (72-80) 68 (64-72)
Range 49-85 55-85 49-82
CCIb 0.61e
≤7 27 (58.7) 8 (53.3) 19 (61.3)
>7 19 (41.3) 7 (46.7) 12 (38.7)
Antiplateletb 0.33c
Yes 20 (43.5) 5 (33.3) 15 (48.4)
No 26 (56.5) 10 (66.7) 16 (51.6)
Anticoagulantb >0.99e
Yes 12 (26.1) 4 (26.7) 8 (25.8)
No 34 (73.9) 11 (73.3) 23 (74.2)
Primary cancerb 0.01e
Bladder 4 (8.7) 4 (26.7) 0 (0)
Colorectal 2 (4.3) 0 (0) 2 (6.5)
Prostate 39 (84.8) 11 (73.3) 28 (90.3)
Vulval 1 (2.2) 0 (0) 1 (3.2)
Stage 0.08c
≤2b 26 (76.5) 6 (54.5) 20 (87.0)
>2b 8 (23.5) 5 (45.5) 3 (13.0)
Missing, n 12 4 8
Treatment modalityb >0.99c
BT 2 (4.3) 0 (0) 2 (6.5)
EBRT 41 (89.1) 14 (93.3) 27 (87.1)
EBRT and BT 3 (6.5) 1 (6.7) 2 (6.5)
Treatment technique 0.03c
IMRTb 12 (63.2) 9 (90.0) 3 (33.3)
LDRb 1 (5.3) 0 (0) 1 (11.1)
VMATb 6 (31.6) 1 (10.0) 5 (55.6)
Missing, n 27 5 22
Treatment intent 0.71c
Adjuvantb 2 (4.9) 0 (0) 2 (7.4)
Curativeb 32 (78.0) 12 (85.7) 20 (74.1)
Palliativeb 2 (4.9) 0 (0) 2 (7.4)
Salvageb 5 (12.2) 2 (14.3) 3 (11.1)
Missing, n 5 1 4
Dose, Gy 0.57e
≤70b 24 (85.7) 7 (77.8) 17 (89.5)
>70b 4 (14.3) 2 (22.2) 2 (10.5)
Missing, n 18 6 12
Fraction 0.84d
Median (IQR) 33 (28-35) 32 (32-33) 33 (26-35)
Range 20-40 23-40 20-37
Dose, Gy per fractionb >0.99c
<2 9 (32.1) 3 (33.3) 6 (31.6)
≥2 19 (67.9) 6 (66.7) 13 (68.4)
  
Characteristic Overall, n=39 Haematuria
Yes, n=30 No, n=9 p-Valuea
Antiplatelet, n (%) >0.99
Yes 18 (46.2) 14 (46.7) 4 (44.4)
No 21 (53.8) 16 (53.3) 5 (55.6)
Antiplatelet name, n (%) >0.99
Aspirin 13 (33.3) 10 (33.3) 3 (33.3)
Aspirin and clopidogrel 1 (2.6) 1 (3.3) 0 (0)
Clopidogrel 4 (10.3) 3 (10.0) 1 (11.1)
None 21 (53.8) 16 (53.3) 5 (55.6)
Anticoagulant, n (%) 0.40
Yes 11 (28.2) 10 (33.3) 1 (11.1)
No 28 (71.8) 20 (66.7) 8 (88.9)
Anticoagulant name, n (%) 0.44
Apixaban 7 (17.9) 7 (23.3) 0 (0)
Rivaroxaban 1 (2.6) 1 (3.3) 0 (0)
Warfarin 3 (7.7) 2 (6.7) 1 (11.1)
None 28 (71.8) 20 (66.7) 8 (88.9)
Indication, n (%) 0.24
AF 8 (27.6) 6 (25.0) 2 (40.0)
CVA 2 (6.9) 2 (8.3) 0 (0)
IHD 9 (31.0) 9 (37.5) 0 (0)
PE 2 (6.9) 2 (8.3) 0 (0)
Primary prevention 7 (24.1) 4 (16.7) 3 (60.0)
VTE 1 (3.4) 1 (4.2) 0 (0)
  
  
  
Characteristic Time from radiotherapy
<5 years, n=5 ≥5 years, n=3
Post RT UC, n (%)
CIS 1 (20.0) 0 (0)
HG pTa 1 (20.0) 0 (0)
LG pTa 2 (40.0) 2 (66.7)
HG pT2 1 (20.0) 1 (33.3)
Age, year
Median (IQR) 74 (69-84) 69 (68-77)
Range 67-85 67-84
CCI, n (%)
≤7 4 (80.0) 2 (66.7)
>7 1 (20.0) 1 (33.3)
Primary cancer, n (%)
Bladder 0 (0) 0 (0)
Colorectal 0 (0) 0 (0)
Prostate 4 (80.0) 2 (66.7)
Vulval 1 (20.0) 1 (33.3)
Treatment modality, n (%)
BT 2 (40.0) 2 (66.7)
EBRT 2 (40.0) 1 (33.3)
EBRT and BT 1 (20.0) 0 (0)
Treatment intent, n (%)
Adjuvant 1 (20.0) 1 (33.3)
Curative 4 (80.0) 2 (66.7)
  
Characteristic Overall, n=103 Delayed late toxicity
<5 years, n=33 ≥5 years, n=70 p-Valuea
RTOG grade 0.020b
Median (IQR) 3 (3-4) 3 (3-3.25) 4 (3-4)
Range 1-4 2-4 1-4
Encounter, n (%) 103 (100) 33 (100) 70 (100)
Admission, n (%) 42 (40.8) 11 (33.3) 31 (44.3) 0.29c
Representation, n (%) 60 (58.3) 23 (69.7) 37 (52.9) 0.11c
Unplanned representation, n (%) 26 (25.2) 7 (21.2) 19 (27.1) 0.52c
Readmission, n (%) 0.55d
Single admission 84 (81.6) 28 (84.8) 56 (80.0)
Readmission 19 (18.4) 5 (15.2) 14 (20.0)
Unplanned readmission, n (%) 13 (12.6) 3 (9.1) 10 (14.3) 0.54c
Encounter category, n (%) 0.047d
Elective 54 (52.4) 22 (66.7) 32 (45.7)
Emergency 49 (47.6) 11 (33.3) 38 (54.3)
Location, n (%) 0.070d
ED 48 (46.6) 10 (30.3) 38 (54.3)
Flexible cystoscopy clinic 22 (21.4) 7 (21.2) 15 (21.4)
OPD 23 (22.3) 11 (33.3) 12 (17.1)
OR 10 (9.7) 5 (15.2) 5 (7.1)
Length of stay, day 0.27b
Median (IQR) 3 (2-4) 2 (1-4.5) 3 (2-4)
Range 1-20 1-20 1-12
Toxicity type, n (%) <0.001d
Necrotic bladder neck contracture 2 (1.9) 0 (0) 2 (2.9)
Clot retention 31 (30.1) 2 (6.1) 29 (41.4)
High pressure retention 1 (1.0) 1 (3.0) 0 (0)
Overactive bladder 6 (5.8) 6 (18.2) 0 (0)
Painless haematuria 34 (33.0) 15 (45.5) 19 (27.1)
RASM 4 (3.9) 1 (3.0) 3 (4.3)
Rectoprostatic fistula 9 (8.7) 3 (9.1) 6 (8.6)
Rectovesical fistula 2 (1.9) 0 (0) 2 (2.9)
Ureteric stricture 3 (2.9) 2 (6.1) 1 (1.4)
Urethral stricture 11 (10.7) 3 (9.1) 8 (11.4)
Procedure category, n (%) 0.51d
No procedure 26 (25.2) 11 (33.3) 15 (21.4)
Non-operative 33 (32.0) 8 (24.2) 25 (35.7)
Operative major 4 (3.9) 1 (3.0) 3 (4.3)
Operative minor 40 (38.8) 13 (39.4) 27 (38.6)
Procedure type, n (%) 0.09d
BNI 1 (1.3) 0 (0) 1 (1.8)
Continuous bladder irrigation 27 (35.1) 5 (22.7) 22 (40.0)
Cystoscopy biopsy 5 (6.5) 3 (13.6) 2 (3.6)
Cystoscopy washout diathermy 3 (3.9) 0 (0) 3 (5.5)
Defunctioning colostomy 1 (1.3) 0 (0) 1 (1.8)
Flexible cystoscopy 20 (26.0) 7 (31.8) 13 (23.6)
IDC procedure 7 (9.1) 1 (4.5) 6 (10.9)
Nephrostomy exchange 1 (1.3) 0 (0) 1 (1.8)
Stent procedure 2 (2.6) 2 (9.1) 0 (0)
TOV 2 (2.6) 2 (9.1) 0 (0)
TURBT 3 (3.9) 1 (4.5) 2 (3.6)
Urethral dilation 5 (6.5) 1 (4.5) 4 (7.3)
  
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