Urinary complications following radiation therapy are increasing in prevalence, challenging to treat, and often require out-of-the-box surgical strategies. In this roundtable discussion, Urology Times Editorial Council member Bradley A. Erickson, MD, speaks with three expert reconstructive urologists—Benjamin N. Breyer, MD, MAS, Sean P. Elliott, MD, MS, and Jeremy B. Myers, MD—about their tips and tricks for managing these complications and their specific approach to three patient cases involving stricture and fistula.
Dr. Erickson: What types of complications from radiation therapy are you managing most often in your reconstructive practice?
Dr. Myers: Brad, thanks for bringing up this topic for discussion. Radiation complications are rarely talked about in the literature or at meetings, but the fact is that they can be absolutely devastating for patients and very challenging to manage. The typical patients we see in Utah are older men after the treatment of prostate cancer and women after the treatment of gynecologic malignancy. These patients have been cured of their disease, but in some cases, they are dealing with the long-term consequences of the treatment that are much worse than their initial cancer.
In Utah, once urologists realized we were willing to work with these patients, we started seeing an increase in the number of referrals for high-grade radiation complications. Those cases make up at least 25% of my current practice. Reconstructive urology is the ideal specialty to bring an “out-of-the-box” surgical strategy to these patients.
We presented an algorithm for the workup of these patients recently in BJUI (2017; 119:700-8). The complications are so varied, and understanding which patients may benefit from lower urinary tract reconstruction versus those that need urinary diversion requires experience with the treatment of urethral and ureteral strictures, rectourethral fistula, and benign urinary diversion; ie, what works and what doesn’t.
Dr. Breyer: These are often very challenging cases, as the radiation has caused damage to the tissue that is irreversible. I’m always impressed by how surprised patients are when they present with a radiation complication, often believing it was a relatively “consequence-free” method of treatment. Erectile dysfunction is common, as is late-onset stress incontinence, which is likely the result of combined outlet dysfunction and bladder overactivity from radiation-induced ischemia.