Options for Men with Severe Radiation Side Effects
By Dr. Daniel S. Elliott, MD
I am a Professor at the Mayo Clinic specifically trained in pelvic reconstructive surgery. I don’t treat prostate cancer. I treat complications that result from prostate cancer treatments. Unlike with surgery, which has side effects that tend to be more immediate, my average patient suffering from radiation complications comes to see me nine years after his treatment.
In simple terms, radiation is a high-energy beam in the form of proton beams or x-rays that are aimed at the prostate to kill the prostate cancer cells. The problem is that in addition to killing the “bad cancer cells” it can also kill the good and healthy cells that make up the parts of the body surrounding the prostate cancer cells, such as the bladder, intestines, and the rectum. Most side effects of radiation are temporary and go away rapidly after the radiation is given. However, this is not true for all the complications, since many of the complications I see occur more than ten years AFTER the radiation has been given.
THE PROGRESSIVE NATURE OF RADIATION:
Since radiation can affect the “good cells” of the bladder and the rectum, it is possible for the damage to continue to progress to the point that new problems appear years after treatment1. This is particularly a problem when talking about older types of less focused radiation. Think of modern radiation as being more like a pencil beam. Older types of radiation were more like spray paint and it was much more common to overspray into the surrounding organs. So let me just offer this aside: It’s extremely important for the man to have multiple opinions from different doctors who see a high volume of patients regularly before they agree to undergo an irreversible type of treatment such as radiation. In this article, we will not deal with the temporary side effects of radiation. Rather, I want to deal with the serious problems I see in my day to day subspecialty practice.
INCONTINENCE AFTER RADIATION:
Usually men will recover urinary control within three to six months after undergoing prostate surgery at a reputable center of excellence. However, if the cancer comes back or if it was not removed completely in the first place, radiation therapy will be recommended. Unfortunately, in a minority of men, the radiation may cause loss of urinary control. The risk of incontinence after surgery is even greater when radiation is administered soon after the operation.
Surgical implantation of a device called an artificial urinary sphincter is effective in controlling the urinary leakage in most cases. This device has been around since 19722. Like with many types of complex surgical procedures, the results are much better with experienced surgeons. Studies show that the surgeon should do at least 10-15 artificial sphincters a year to be merely competent.3 The surgeon should have done at least 200 in her/his career to be considered an expert.4
BLADDER NECK SCARRING:
If the tissue where the bladder opens into the urethra becomes damaged after radiation (or after surgery) it can lead to blockage of the urinary passage (called urinary retention). This can be a medical emergency because the urine has no way of getting out. Treatment for this usually involves stretching the urethra/bladder neck by forcing steel probes up the urethra with a procedure under general anesthesia. Frequently, though not always, stretching alone works. Sometimes, however, scar tissue can break instead of stretch and can result in severe urinary leakage, which will also require an artificial urinary sphincter to repair.
URINATION PROBLEMS:
Longstanding urination problems such as urinary urgency, frequency, burning with urination, and getting up at night to urinate are also potentially serious complications of radiation. The main problem with these conditions is that medications such as Flomax, Myrbetriq, Cialis and the like only control mild to moderate degrees of urinary dysfunction. When it is really severe, we try hyperbaric oxygen (HBO) to help ease the urination problems, but often only with limited success. Some experts claim results with pentoxyphylene and vitamin E. In rare cases, I have to remove the bladder surgically, a situation we call “end-stage bladder.”
RADIATION CYSTITIS:
When radiation causes severe inflammation of the bladder lining, it becomes so frail that the blood vessels break easily and bleed, turning a man’s urine bright red with blood. Rarely, this condition can be a medical emergency, requiring a trip to the operating room to try to control the bleeding. For milder urinary bleeding, we also try hyperbaric oxygen5.
FISTULA FORMATION:
Another rare but serious complication is where a hole can develop between the bladder or prostate and another organ; this is called a fistula. If this hole connects with either the pubic bone it is called a puboprostatic fistula. If it connects with the rectum it is called a rectourethral fistula. Fistulas can lead to infections of the bone, pelvis, and bladder. Almost always this dire condition requires surgery to remove the bladder and pubic bone or rectum6. Fortunately, this condition is very rare, but even so,
due to my highly specialized referral practice, I still see about ten to twenty men a year with this problem. If this condition occurs, it’s critical to seek out a specialist who works with an advanced multi-specialty surgical team—an orthopedic reconstructive surgeon, a colorectal reconstructive surgeon, and a urologic reconstructive surgeon.
IMPOTENCE:
Treatments such as Viagra, Cialis or injection therapy will enable most men with impotence to have their erections restored. Men who are highly motivated and who have failed these standard measures should consider consulting an experienced expert regarding the possibility of having an inflatable penile prosthesis (IPP) surgically implanted. Again, as with the artificial urinary sphincter, it is vital for the man desiring an IPP to seek out a highly trained, large volume specialist to ensure the highest chance of success and to avoid preventable complications.
CONCLUSION:
Sadly, many of the severe complications I see could have been prevented if the patient was treated with state-of-the-art radiation from an expert provider. Even so, there will always be some risk of unexpected severe side effects no matter what type of treatment you choose. If severe problems such as those described above do occur, it is very important to consult with a doctor with experience managing such serious side effects. Less skilled interventions have the potential to make the problem worse.
I’ve included some medical articles that go into much more detail regarding what I’ve mentioned above. These articles are usually readily available on the internet and can serve as a good source of information that you can use in discussions with your doctor.
References:
1. Lomas D, Ziegelmann M, Elliott DS: How informed is our consent? Patient awareness of radiation and radical prostatectomy compilations. Turk J. Urol 2018. DOI: 10.5152/tud.2018.81522.
2. Rivera; Linder; Elliott DS: The impact of prior radiation therapy on artificial sphincter device survival. J Urol. 2016 Apr;195(4 Pt 1):1033-7.
3. Lai H, Boone T: The surgical learning curve of artificial urinary sphincter implantation: implications for prosthetic training and referral. 2013 Apr;189(4):1437-43.
4. Sandhu J et al: The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience. Eur Urol. 2011 Dec;60(6):1285-90.
5. Linder B, Boorjian S: Cystectomy for refractory hemorrhagic cystitis: contemporary etiology, presentation and outcomes. J Urol. 2014 Dec;192(6):1687-92.
6. Linder B; Umbreit E; Larson D; Elliott DS: Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas. J Urol. 2013 Oct;190(4):1287-91.
About Dr. Elliott:
Dr. Daniel S. Elliott, MD, is a professor of urology in the section of pelvic and reconstructive surgery at the Mayo Clinic in Rochester, Minnesota.