title: Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer.
abstract: To describe the management of Radiation Therapy Oncology Group (RTOG) grade 4 urinary adverse events (UAEs) after radiotherapy (RT) for prostate cancer (PCa).
  
  
  
  We conducted a single-centre retrospective review, over a 6-year period (2010-2015), to identify men with RTOG grade 4 UAEs after RT for PCa. RT was classified as combined therapy (radical prostatectomy [RP] followed by external beam radiotherapy [EBRT], EBRT + low-dose-rate [LDR] brachytherapy, EBRT + high-dose-rate [HDR] brachytherapy or other combinations of RT) or monotherapy RT. UAEs were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, or recto-urethral fistula) or bladder (contraction, necrosis, fistula, ureteric stricture or haemorrhage) UAEs.
  
  
  
  We identified 73 men with a mean age of 73 years. Of these, 44 (60%) received combined therapy, consisting of RP + EBRT (n = 19), HDR brachytherapy + EBRT (n = 19), LDR brachytherapy + EBRT (n = 5), and other combined RT (n = 1). Twenty-nine (40%) patients had monotherapy consisting of EBRT (n = 4), HDR brachytherapy (n = 11), LDR brachytherapy (n = 12), or proton beam therapy (n = 2). UAEs were isolated to the bladder in six men (8%), the outlet in 52 men (71%), and to both in 15 men (21%). UAE management included: conservative in 21 (29%), indwelling catheters in 12 (16%), reconstructive in 19 (26%), and urinary diversion (UD) in 23 men (32%). Reconstruction included: ureteric (n = 4), recto-urethral fistula repair (n = 2), and posterior urethroplasty (n =13), of which 14/16 surgeries (88%) with follow-up >90 days were successful.
  
  
  
  Although the incidence of RTOG grade 4 UAEs after PCa radiation treatment is not well defined, their associated morbidity is significant, and approximately one third of patients with these high-grade complications require UD. Conversely, only about a quarter of patients can be managed with conservative strategies or local surgeries. Reconstruction is successful in selected patients.
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: Erik N
authors.identifier: 0000-0003-3149-7139
authors.initials: EN
authors.lastname: Mayer
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Tward
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: Mitchell
authors.initials: M
authors.lastname: Bassett
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: Sara M
authors.initials: SM
authors.lastname: Lenherr
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Hotaling
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: William O
authors.initials: WO
authors.lastname: Brant
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: William T
authors.initials: WT
authors.lastname: Lowrance
authors.affiliation: Department of Surgery, Center for Reconstructive Urology and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
authors.forename: Jeremy B
authors.initials: JB
authors.lastname: Myers
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D006801:Humans; D008297:Male; D008875:Middle Aged; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011878:Radiotherapy / Q000009:adverse effects; D012189:Retrospective Studies; D014570:Urologic Diseases / Q000209:etiology* / Q000628:therapy*
keywords: complications; management; prostate cancer; radiation; treatment