title: Devastating complications after brachytherapy in the treatment of prostate adenocarcinoma.
abstract: 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.
  
  
  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.
authors.affiliation: Division of Urology, Department of Interdisciplinary Oncology Group and Surgery, H. Lee Moffitt Cancer Research Institute, University of South Florida Health Sciences Center, Tampa, Florida, USA. smoreira@hsc.usf.edu
authors.forename: S G
authors.initials: SG
authors.lastname: Moreira
authors.forename: J D
authors.initials: JD
authors.lastname: Seigne
authors.forename: R C
authors.initials: RC
authors.lastname: Ordorica
authors.forename: J
authors.initials: J
authors.lastname: Marcet
authors.forename: J M
authors.initials: JM
authors.lastname: Pow-Sang
authors.forename: J L
authors.initials: JL
authors.lastname: Lockhart
mesh_terms: D000230:Adenocarcinoma / Q000532:radiotherapy*; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000009:adverse effects*; D015653:Cystectomy / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D011468:Prostatectomy / Q000379:methods; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D012003:Rectal Fistula / Q000209:etiology* / Q000601:surgery; D012008:Recurrence; D012189:Retrospective Studies; D014522:Urethral Diseases / Q000209:etiology* / Q000601:surgery; D001745:Urinary Bladder Diseases / Q000209:etiology* / Q000601:surgery; D014547:Urinary Diversion / Q000379:methods; D014548:Urinary Fistula / Q000209:etiology* / Q000601:surgery