0022-5347/90/1442-0305$02.00/0 THEJOURNAL O F UROLOGY Copyright C 1990 by AMERICAN UROLOGICAL ASSOCIATION. INC
Voi. 144, A U ~ U S ~
Printed in L:S.A.
PROSTATE CANCER: POST-IRRADIATION INCONTINENCE NATHAN G R E E N , DALE TREHBLE
AND
HARVEY WALLACK
From the Divisions of Radiation Therapy and Lrrology, Valley Presbyterian Hospital, V a n Nuys, and Division of Urology, Los Robles Hospital, Thousand Oaks, California
ABSTRACT
T h e experience of 272 patients with prostate cancer treated between 1976 a n d 1987 by external irradiation w a s reviewed t o assess causal factors for post-irradiation incontinence a n d t o determine measures t o reduce t h e risk of this complication. N o patient h a d incontinence before definitive irradiation o r radical prostatectomy. Post-irradiation incontinence was observed i n 19 of 272 patients ( 7 % ) , including 14 with mild, 2 with moderate a n d 3 with severe disease. Incontinence after definitive irradiation was not significantly related t o t u m o r stage o r t u m o r control: 8 of 192 patients (4%) h a d local control a n d 2 of 3 3 (6%) h a d local failure. Incontinence was related t o a urological operation performed in 1 of 105 patients (1%) who underwent needle biopsy a n d 7 of 130 (5.5%) who underwent transurethral prostatectomy before irradiation. Incontinence was more frequent, 2 of 6 p a t i e n t s (33%), a n d more severe i n patients who underwent transurethral prostatectomy after irradiation. Of 31 patients 9 (29%) were incontinent after radical prostatectomy. N o additional patient h a d incontinence after postoperative irradiation. However, 3 patients had a temporary increase i n t h e severity of incontinence. T h e risk of post-irradiation incontinence m a y be decreased by more selective use of transurethral prostatectomy. Of 136 patients 26 (20%) underwent transurethral prostatectomy for tissue diagnosis. A needle biopsy would be t h e procedure of choice. A total of 29 patients with urinary outlet obstruction was treated without transurethral prostatectomy before irradiation. T e n patients w i t h relatively mild urinary outlet obstruction were treated b y irradiation alone, while 19 with more severe urinary outlet obstruction h a d endocrine therapy before irradiation a n d none of t h e 29 patients ( 0 % ) h a d post-irradiation incontinence. (J.Urol., 144: 307-309, 1990) There has been considerable debate with regard to the relative merit of radiation therapy and radical prostatectomy for the management of localized prostate cancer. Proponents for each modality have based the decision on the probability of achieving tumor control and survival free of disease with acceptable A reservation with regard to radical prostatectomy has been postoperative urinary incontinence. Although uncommon, urinary incontinence also has been attributed to radiation therapy. It is unclear whether surgical trauma from either transurethral or radical prostatectomy predisposes to irradiation i n c ~ n t i n e n c e .We ~ , ~studied post-irradiation urinary incontinence as it relates to tumor stage, tumor control and urological operations, and evaluated measures that could be used to avoid this complication. MATERIAL AND METHODS
Between October 1, 1975 and October 1, 1987, 321 patients were seen at the division of radiation therapy for definitive or adjunctive postoperative irradiation. Of the patients 272 underwent either a needle biopsy (105), or transurethral (136) or radical (31) prostatectomy and they comprise the study group for this report. Transurethral prostatectomy was done before irradiation in 130 patients (104 to alleviate urinary outlet obstruction and to obtain a tissue diagnosis, while 26 did not have urinary obstruction and resection was done solely to obtain tissue diagnosis) and 6 underwent transurethral prostatectomy after irradiation and were analyzed separately. Of the 31 patients who underwent radical prostatectomy 28 received adjunctive postoperative irradiation and 3 received definitive irradiation for local recurrence. Followup ranged from 18 months to 12 years, with a median of 3 years (127 patients were followed for 3 years, 82 for 5 to 9 years and 10 for 10 to 12 years). Patient age ranged from 45 to 89 years, with a median of 69 years. Accepted for publication February 26, 1990.
The disease was staged according to the extent of tumor spread as judged by rectal examination, operative findings, blood acid phosphatase levels, isotope bone scan, pelvic computerized axial tomography and bipedal lymphangiography. Staging laparotomy was done in 52 patients. The disease was staged clinically according to the local extent in 241 patients (23 had stage A2, 37 stage B1, 38 stage B2, 94 stage C1 and 49 stage C2 tumor). Pathological status was categorized as low grade in 69 patients, intermediate grade in 116 and high grade in 87.',' Definitive irradiation was delivered with a 4, 6 or 18 MEV. linear accelerator using opposing anterior and posterior portals to the entire pelvis and arc or rotation to the prostate: 160 to 180 cGy. per day for 5 days per week to a total dose of 4,500 to 4,800 cGy. to the pelvis, and 5,500 cGy. to the prostate. Adjunctive postoperative irradiation was delivered to a dose of 4,500 to 6,500 cGy. After definitive irradiation the response of the primary tumor was recorded a t 6-month to 1-year intervals. Local control was judged if the prostate reverted to normal size and consistency or if the prostate was no longer palpable. Routine post-irradiation biopsies were not done. Local failure was judged if there was a persistent or recurrent area of induration. Tumor control was indeterminate in 16 patients, since the duration of followup was less than 2 years. The impact of tumor control and urological operations performed on the frequency and severity of post-irradiation incontinence was assessed. RESULTS
Urinary incontinence was observed in 19 of 272 patients (7%): 14 had mild, 2 had moderate and 3 had severe disease. Over-all, 9 patients had active, 5 had stress and 5 had urgency incontinence. Ten of 241 patients (4%) had incontinence after definitive irradiation: 8 of 192 (4%) had local tumor control and 2 of 33 (6%) had local tumor failure. Incontinence was
308
GREEN, TREIBLE AND WALLACK
unrelated to tumor stage. The onset of incontinence ranged from 6 months to 10 years (median 2l/2 years). Mild incontinence occurred in 1of 105 patients (1%) who underwent needle biopsy and 7 of 130 (5.5%) who underwent transurethral prostatectomy before irradiation (table 1). A total of 29 patients with urinary outlet obstruction did not undergo transurethral prostatectomy before irradiation. Ten patients with mild urinary outlet obstruction as judged by the urologist received irradiation alone, while 19 judged to have more severe urinary outlet obstruction received endocrine therapy for 6 to 8 weeks before irradiation and none of these 29 patients (0%) had post-irradiation incontinence. Of 6 patients who underwent transurethral prostatectomy after completion of irradiation 2 (33%)had moderate or severe incontinence at 1 and 5 months (1had local failure and 1 had local control). Nine of 31 patients (29%) had incontinence after radical prostatectomy. No additional patient had incontinence after postoperative irradiation (table 1). However 3 patients did have a transient increase in t h e severity of incontinence after irradiation (table 2). DISCUSSION
A
Urinary incontinence is one of the more distressing complaints to occur in patients with prostate cancer. The male anatomy includes a proximal and distal urethral sphincter. Either sphincter by itself can maintain continence.1° Urethral insufficiency occurs only when the proximal and distal urethral sphincters have been compromised. Urodynamic studies have shown that patients with incontinence have a shortened functional urethra and decreased maximum closing pressure. The ability of the sphincter t o compensate with the patient in the standing position is impaired.'' Removal of the proximal third of the distal urethral sphincter via transurethral prostatectomy is not followed by incontinence. Radical prostatectomy removes the proximal two-thirds of the distal urethral sphincter and leaves only the distal third to maintain continence. Avoidance of surgical damage of the remaining sphincter is of paramount importance. Radiation fibrosis and tumor invasion can damage the sphincter and compromise function."1° The incidence of incontinence depends to a considerable degree on the diligence with which patients are interviewed. Our patients had specific inquiry a t each followup and 4% had incontinence after definitive irradiation. Incontinence usually occurred within 2 years. This finding contrasted with approximately 30% of the patients who had incontinence after radical prostatectomy. Post-irradiation urinary incontinence often is multifactorial. In our experience surgical trauma was the most important TABLE1. Urinary incontinence Onset of Incontinence Total NO. pts,
Urological Procedure
Postop. No.
Preop, No,
After Irradiation No. ( % I
(5%) lkeedle biopsy Transurethral prostatectomy Radical prostatectomy
105 0 (0) 130 0 (0) 31 0 (0) " Excludes 6 patients who underwent transuretllral diation.
0 (0)
1 (1) 7 (5.5)* 9 (29) 9 (29) prostatectomy after irra0 (0)
TABLE2. Radical ~rostatectomv Severity of Incontinence Mild Moderate Severe
Total KO. pts. 9 9 9
Onset of Incontinence (KO.~ t s . ) After Irradiation Before Irradiation 6 1
2
contributory factor. Approximately 1% of the patients who underwent needle biopsy had post-irradiation incontinence. This finding was comparable to the community prevalence in men not actively seeking medical attention.'' Incontinence after transurethral prostatectomy alone is uncommon. Transurethral prostatectomy is done with the instrument inserted through the distal urethral sphincter to resect proximal to the apex of the prostate. The distal urethral sphincter may be inadvertently injured.12 None of our patients who underwent transurethral prostatectomy was incontinent before irradiation, while 50% had mild incontinence after irradiation. A third of the patients who underwent transurethral prostatectomy after irradiation had moderate or severe incontinence. Persistent or recurrent cancer could have been a contributory f a ~ t o rHow.~ ever, in our experience a tumor recurrence did not seem t o impact upon radiation-induced incontinence. Rather, the incontinence in one of the local failure groups occurred immediately after transurethral prostatectomy. The frequency of incontinence after radical prostatectomy in our patients was comparable to the experience at other cent e r ~ . ~The , ' ~role of postoperative irradiation has been debated. Irradiation may prevent local recurrence and improve survival. On the other hand. irradiation mav increase the freauencv" and severity of postoperative incontinknce. It also can predispose to operative complications in patients who undergo insertion of an artificial urinary ~phincter.~>'~-~"e used adjunctive irradiation if a tumor was a t the margin of resection or there was seminal vesicle invasion. No additional patient was incontinent after irradiation, while some did have an increase in severity of incontinence that lasted several months. The mechanism is unclear. Fibrosis of the urethral sphincter was an unlikely cause, since the incontinence was reversible. A transient decrease in bladder compliance may occur with the irradiation.lgThis could cause an increase in intravesical pressure resulting in incontinence. The risk of post-irradiation incontinence may be decreased by the more selective use of transurethral prostatectomy. Of our patients without urinary obstruction 20% underwent transurethral prostatectomy for tissue diagnosis. A needle biopsy would have been the procedure of choice. Most of our patients with urinary outlet obstruction underwent transurethral prostatectomy before irradiation. Irradiation was delayed for 6 to 8 weeks postoperatively to allow for urethral healing. Transurethral prostatectomy was done because of concern that urinary obstruction might increase after the initiation of irradiation. The patient would then require transurethral prostatectomy or catheter drainage while undergoing irradiation. Such an event could increase the risk of irradiation complications. Also, interruption of irradiation to allow for urethral healing could decrease tumor c o n t r ~ l . In ~ ' ~our ~ experience transurethral prostatectomy may not be necessary if patients have only mild urinary outlet obstruction. Irradiation alone was effective in such patients. None had a significant increase in obstruction while undergoing irradiation. All of the patients were managed conservatively. A number of patients judged to have more severe urinary outlet obstruction were treated by endocrine therapy before irradiation. The obstruction was alleviated and none had post-irradiation incontinence. The addition of endocrine therapy to irradiation also may improve tumor control and ~ u r v i v a l . ' ~ Accordingly, ~*~ a trial of endocrine therapy should be considered as the initial treatment for patients with moderately severe obstruction. Transurethral prostatectomy could be reserved for patients who have tumor refractory to endocrine therapy. After irradiation every effort also should be made to avoid urethral trauma. In our experience incontinence was more frequent and more severe if transurethral prostatectomy was done after irradiation compared to before irradiation. Again, a trial of endocrine therapy should be considered as the initial treatment of urinary outlet obstruction from recurrent cancer.
3 Mos.
1 Yr.
3 Yrs.
3 4 2
6 1
6 1 2
2
PROSTATE CANCER: POST-IRRADIATION INCONTINENCE Assistance w i t h t h i s s t u d y w a s provided b y Drs. B a s s a m Bejjani, H e n r y B o d n e r , E u g e n e M. B r o t h , C h i n g Chiang, J e r r y S. G a r r e t t , H a r v e y W. Goldberg, A b r a h a m M. B. Goldstein, R o b e r t L. Gray, Vincent; Gualtieri, M a r c e l I. Horowitz, J a c k A. Jaffe, R o n a l d J. K a p l a n , Floyd A. K a t s k e , S t e p h e n Kugler, P h i l i p K u r z n e r , G a r y Lieskovsky, Louis J. Lombardo, J r . , R o b e r t Michaels, D o n a l d Motzkin, R i c h a r d C. Onofrio, R e n e O s m a n , S a n f o r d L. Polse, S t a n l e y C. Ross, R o b e r t Saffian, Isadore R. Schlossberg, R i c h a r d A. Shapiro, L e o n a r d B. Skaist, D o n a l d G. S k i n n e r , J. B r a d l e y T a y l o r , A r t h u r V a t z a n d Harley Wishner. REFERENCES
1. Hanks, G. E.: Radical prostatectomy or radiation therapy for early prostate cancer. Two roads t o the same end. Cancer, 61: 2153, 1988. 2. Jewett, H. J.: Prostatic cancer: a personal view of the problem. J . Urol., 131: 845, 1984. 3. Lindner, A,, deKernion, J. B., Smith, R. B. and Katske, F. A.: Risk of urinary incontinence following radical prostatectomy. J . Urol., 129: 1007, 1983. 4. Paulson, D. F., Lin, G. H., Hinshaw, W., Stephani, S. and the UroOncology Research Group: Radical surgery versus radiotherapy for adenocarcinoma of the prostate. J . Urol., 128: 502, 1982. 5. Pilepich, M. V., Perez, C. A., Walz, B. J , and Zivnuska, F. R.: Complications of definitive radiotherapy for carcinoma of the prostate. Int. J. Rad. Oncol. Biol. Phys., 7: 1341, 1981. 6. Kaufman, J . J., Smith, R. B. and Raz, S.: Radiation therapy in carcinoma of t h e prostate: a contributing cause of urinary incontinence. J . Urol., 132: 998, 1984. 7. Perez, C. A., Ackerman, L. V., Silber, I. and Royce, R. K.: Radiation therapy in the treatment of localized carcinoma of the prostate. Preliminary report using 22-MeV photons. Cancer, 34: 1059, 1974. 8. Beahrs, 0 . H., Henson, D. E., Hutler, R. V. and Myers, M. H.: Manual for Staging of Cancer, 3rd ed. Philadelphia: J. B. Lippincott Co., chapt, 29, pp. 177-179, 1988. 9. Epstein, J . P.: T h e prostate and seminal vesicle. In: Diagnostic Surgical Pathology. Edited by Stephen S. Sternberg. New York: Raven Press, chapt. 41, pp. 1401-1409, 1989. 10. Hadley, H. R., Zimmern, P. E. and Raz, S.: The treatment of male urinary incontinence. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T . A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 72, pp. 26582679, 1986.
309
11. Rudy, D. C., Woodside, J. R. and Crawford, E. D.: Urodynamic evaluation of incontinence in patients undergoing modified Campbell radical retropubic prostatectomy: a prospective study. J . Urol., 132: 708, 1984. 12. Glenn, J. F.: Surgical therapy of cancer of the prostate. In: Genitourinary Cancer. Edited by D. G. Skinner and J . B. deKernion. Philadelphia: W. B. Saunders Co., chapt. 18, pp. 344-354, 1978. 13. Igel, T . C., Barrett, D. M., Segura, J. W., Benson, R. C., Jr. and Rife, C. C.: Perioperative and postoperative complications from bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. J . Urol., 137: 1189, 1987. 14. Anscher, M. S. and Prosnitz, L. R.: Postoperative radiotherapy for patients with carcinoma of the prostate undergoing radical prostatectomy with positive surgical margins, seminal vesicle involvement and/or penetrationthrough the capsule. J. Urol., 138: 1407,1987. 15. Barrett, D. M. and Furlow, W. L.: Radical prostatectomy incontinence and the AS791 artificial urinary sphincter. J . Urol., 129: 528, 1983. 16. Middleton, R. G., Smith, J . A., Jr., Melzer, R. B. and Hamilton, P. E.: Patient survival and local recurrence rate following radical prostatectomy for prostatic carcinoma. J. Urol., 136: 422, 1986. 17. Skinner, D. G. and Lieskovsky, G.: Carcinoma of the prostate: an opinion on management of early stage disease with a commentary on the meaning of capsular penetration. J . Urol., 134: 1183, 1985. 18. Bagshaw, M. A,: Radiation therapy for cancer of the prostate. In: Genitourinary Cancer. Edited by D. G. Skinner and J . B. deKernion. Philadelphia: W. B. Saunders Co., chapt. 19, pp. 355379, 1978. 19. Pilepich, M. V., Asbell, S. O., Krall, J. M., Baerwald, W. H., Sause, W. T., Rubin, P., Emami, B. N. and Pidcock, G. M.: Correlation of radiotherapeutic parameters and treatment related morbidity-analysis of RTOG study 77-06. Int. J . Rad. Oncol. Biol. Phys., 3: 1007, 1987. 20. Green, N., Bodner, H., Broth, E., Chiang, C., Garrett, J., Goldstein, A., Goldberg, H., Gualtieri, V., Gray, R., Jaffe, J., Kaplan, R., Polse, S., Ross, S., Skaist, L., Treible, D., Vatz, A. a n d Wallack, H.: Improved control of bulky prostate carcinoma with sequential ; estrogen and radiation therapy. Int. J. Rad. Oncol. ~ i o l Phys., 10: 971, 1984. 21. Zagars, G. K., Johnson, D. E., Von Eschenbach, A. C. a n d Hussey, A. H.: Adjuvant estrogen following radiation therapy for stage C adenocarcinoma of the prostate: long-term results of a prospective randomized study. Int. J. Rad. Oncol. Biol. Phys., 14: 1085, 1988.
Voi. 144, A U ~ U S ~
Printed in L:S.A.
PROSTATE CANCER: POST-IRRADIATION INCONTINENCE NATHAN G R E E N , DALE TREHBLE
AND
HARVEY WALLACK
From the Divisions of Radiation Therapy and Lrrology, Valley Presbyterian Hospital, V a n Nuys, and Division of Urology, Los Robles Hospital, Thousand Oaks, California
ABSTRACT
T h e experience of 272 patients with prostate cancer treated between 1976 a n d 1987 by external irradiation w a s reviewed t o assess causal factors for post-irradiation incontinence a n d t o determine measures t o reduce t h e risk of this complication. N o patient h a d incontinence before definitive irradiation o r radical prostatectomy. Post-irradiation incontinence was observed i n 19 of 272 patients ( 7 % ) , including 14 with mild, 2 with moderate a n d 3 with severe disease. Incontinence after definitive irradiation was not significantly related t o t u m o r stage o r t u m o r control: 8 of 192 patients (4%) h a d local control a n d 2 of 3 3 (6%) h a d local failure. Incontinence was related t o a urological operation performed in 1 of 105 patients (1%) who underwent needle biopsy a n d 7 of 130 (5.5%) who underwent transurethral prostatectomy before irradiation. Incontinence was more frequent, 2 of 6 p a t i e n t s (33%), a n d more severe i n patients who underwent transurethral prostatectomy after irradiation. Of 31 patients 9 (29%) were incontinent after radical prostatectomy. N o additional patient h a d incontinence after postoperative irradiation. However, 3 patients had a temporary increase i n t h e severity of incontinence. T h e risk of post-irradiation incontinence m a y be decreased by more selective use of transurethral prostatectomy. Of 136 patients 26 (20%) underwent transurethral prostatectomy for tissue diagnosis. A needle biopsy would be t h e procedure of choice. A total of 29 patients with urinary outlet obstruction was treated without transurethral prostatectomy before irradiation. T e n patients w i t h relatively mild urinary outlet obstruction were treated b y irradiation alone, while 19 with more severe urinary outlet obstruction h a d endocrine therapy before irradiation a n d none of t h e 29 patients ( 0 % ) h a d post-irradiation incontinence. (J.Urol., 144: 307-309, 1990) There has been considerable debate with regard to the relative merit of radiation therapy and radical prostatectomy for the management of localized prostate cancer. Proponents for each modality have based the decision on the probability of achieving tumor control and survival free of disease with acceptable A reservation with regard to radical prostatectomy has been postoperative urinary incontinence. Although uncommon, urinary incontinence also has been attributed to radiation therapy. It is unclear whether surgical trauma from either transurethral or radical prostatectomy predisposes to irradiation i n c ~ n t i n e n c e .We ~ , ~studied post-irradiation urinary incontinence as it relates to tumor stage, tumor control and urological operations, and evaluated measures that could be used to avoid this complication. MATERIAL AND METHODS
Between October 1, 1975 and October 1, 1987, 321 patients were seen at the division of radiation therapy for definitive or adjunctive postoperative irradiation. Of the patients 272 underwent either a needle biopsy (105), or transurethral (136) or radical (31) prostatectomy and they comprise the study group for this report. Transurethral prostatectomy was done before irradiation in 130 patients (104 to alleviate urinary outlet obstruction and to obtain a tissue diagnosis, while 26 did not have urinary obstruction and resection was done solely to obtain tissue diagnosis) and 6 underwent transurethral prostatectomy after irradiation and were analyzed separately. Of the 31 patients who underwent radical prostatectomy 28 received adjunctive postoperative irradiation and 3 received definitive irradiation for local recurrence. Followup ranged from 18 months to 12 years, with a median of 3 years (127 patients were followed for 3 years, 82 for 5 to 9 years and 10 for 10 to 12 years). Patient age ranged from 45 to 89 years, with a median of 69 years. Accepted for publication February 26, 1990.
The disease was staged according to the extent of tumor spread as judged by rectal examination, operative findings, blood acid phosphatase levels, isotope bone scan, pelvic computerized axial tomography and bipedal lymphangiography. Staging laparotomy was done in 52 patients. The disease was staged clinically according to the local extent in 241 patients (23 had stage A2, 37 stage B1, 38 stage B2, 94 stage C1 and 49 stage C2 tumor). Pathological status was categorized as low grade in 69 patients, intermediate grade in 116 and high grade in 87.',' Definitive irradiation was delivered with a 4, 6 or 18 MEV. linear accelerator using opposing anterior and posterior portals to the entire pelvis and arc or rotation to the prostate: 160 to 180 cGy. per day for 5 days per week to a total dose of 4,500 to 4,800 cGy. to the pelvis, and 5,500 cGy. to the prostate. Adjunctive postoperative irradiation was delivered to a dose of 4,500 to 6,500 cGy. After definitive irradiation the response of the primary tumor was recorded a t 6-month to 1-year intervals. Local control was judged if the prostate reverted to normal size and consistency or if the prostate was no longer palpable. Routine post-irradiation biopsies were not done. Local failure was judged if there was a persistent or recurrent area of induration. Tumor control was indeterminate in 16 patients, since the duration of followup was less than 2 years. The impact of tumor control and urological operations performed on the frequency and severity of post-irradiation incontinence was assessed. RESULTS
Urinary incontinence was observed in 19 of 272 patients (7%): 14 had mild, 2 had moderate and 3 had severe disease. Over-all, 9 patients had active, 5 had stress and 5 had urgency incontinence. Ten of 241 patients (4%) had incontinence after definitive irradiation: 8 of 192 (4%) had local tumor control and 2 of 33 (6%) had local tumor failure. Incontinence was
308
GREEN, TREIBLE AND WALLACK
unrelated to tumor stage. The onset of incontinence ranged from 6 months to 10 years (median 2l/2 years). Mild incontinence occurred in 1of 105 patients (1%) who underwent needle biopsy and 7 of 130 (5.5%) who underwent transurethral prostatectomy before irradiation (table 1). A total of 29 patients with urinary outlet obstruction did not undergo transurethral prostatectomy before irradiation. Ten patients with mild urinary outlet obstruction as judged by the urologist received irradiation alone, while 19 judged to have more severe urinary outlet obstruction received endocrine therapy for 6 to 8 weeks before irradiation and none of these 29 patients (0%) had post-irradiation incontinence. Of 6 patients who underwent transurethral prostatectomy after completion of irradiation 2 (33%)had moderate or severe incontinence at 1 and 5 months (1had local failure and 1 had local control). Nine of 31 patients (29%) had incontinence after radical prostatectomy. No additional patient had incontinence after postoperative irradiation (table 1). However 3 patients did have a transient increase in t h e severity of incontinence after irradiation (table 2). DISCUSSION
A
Urinary incontinence is one of the more distressing complaints to occur in patients with prostate cancer. The male anatomy includes a proximal and distal urethral sphincter. Either sphincter by itself can maintain continence.1° Urethral insufficiency occurs only when the proximal and distal urethral sphincters have been compromised. Urodynamic studies have shown that patients with incontinence have a shortened functional urethra and decreased maximum closing pressure. The ability of the sphincter t o compensate with the patient in the standing position is impaired.'' Removal of the proximal third of the distal urethral sphincter via transurethral prostatectomy is not followed by incontinence. Radical prostatectomy removes the proximal two-thirds of the distal urethral sphincter and leaves only the distal third to maintain continence. Avoidance of surgical damage of the remaining sphincter is of paramount importance. Radiation fibrosis and tumor invasion can damage the sphincter and compromise function."1° The incidence of incontinence depends to a considerable degree on the diligence with which patients are interviewed. Our patients had specific inquiry a t each followup and 4% had incontinence after definitive irradiation. Incontinence usually occurred within 2 years. This finding contrasted with approximately 30% of the patients who had incontinence after radical prostatectomy. Post-irradiation urinary incontinence often is multifactorial. In our experience surgical trauma was the most important TABLE1. Urinary incontinence Onset of Incontinence Total NO. pts,
Urological Procedure
Postop. No.
Preop, No,
After Irradiation No. ( % I
(5%) lkeedle biopsy Transurethral prostatectomy Radical prostatectomy
105 0 (0) 130 0 (0) 31 0 (0) " Excludes 6 patients who underwent transuretllral diation.
0 (0)
1 (1) 7 (5.5)* 9 (29) 9 (29) prostatectomy after irra0 (0)
TABLE2. Radical ~rostatectomv Severity of Incontinence Mild Moderate Severe
Total KO. pts. 9 9 9
Onset of Incontinence (KO.~ t s . ) After Irradiation Before Irradiation 6 1
2
contributory factor. Approximately 1% of the patients who underwent needle biopsy had post-irradiation incontinence. This finding was comparable to the community prevalence in men not actively seeking medical attention.'' Incontinence after transurethral prostatectomy alone is uncommon. Transurethral prostatectomy is done with the instrument inserted through the distal urethral sphincter to resect proximal to the apex of the prostate. The distal urethral sphincter may be inadvertently injured.12 None of our patients who underwent transurethral prostatectomy was incontinent before irradiation, while 50% had mild incontinence after irradiation. A third of the patients who underwent transurethral prostatectomy after irradiation had moderate or severe incontinence. Persistent or recurrent cancer could have been a contributory f a ~ t o rHow.~ ever, in our experience a tumor recurrence did not seem t o impact upon radiation-induced incontinence. Rather, the incontinence in one of the local failure groups occurred immediately after transurethral prostatectomy. The frequency of incontinence after radical prostatectomy in our patients was comparable to the experience at other cent e r ~ . ~The , ' ~role of postoperative irradiation has been debated. Irradiation may prevent local recurrence and improve survival. On the other hand. irradiation mav increase the freauencv" and severity of postoperative incontinknce. It also can predispose to operative complications in patients who undergo insertion of an artificial urinary ~phincter.~>'~-~"e used adjunctive irradiation if a tumor was a t the margin of resection or there was seminal vesicle invasion. No additional patient was incontinent after irradiation, while some did have an increase in severity of incontinence that lasted several months. The mechanism is unclear. Fibrosis of the urethral sphincter was an unlikely cause, since the incontinence was reversible. A transient decrease in bladder compliance may occur with the irradiation.lgThis could cause an increase in intravesical pressure resulting in incontinence. The risk of post-irradiation incontinence may be decreased by the more selective use of transurethral prostatectomy. Of our patients without urinary obstruction 20% underwent transurethral prostatectomy for tissue diagnosis. A needle biopsy would have been the procedure of choice. Most of our patients with urinary outlet obstruction underwent transurethral prostatectomy before irradiation. Irradiation was delayed for 6 to 8 weeks postoperatively to allow for urethral healing. Transurethral prostatectomy was done because of concern that urinary obstruction might increase after the initiation of irradiation. The patient would then require transurethral prostatectomy or catheter drainage while undergoing irradiation. Such an event could increase the risk of irradiation complications. Also, interruption of irradiation to allow for urethral healing could decrease tumor c o n t r ~ l . In ~ ' ~our ~ experience transurethral prostatectomy may not be necessary if patients have only mild urinary outlet obstruction. Irradiation alone was effective in such patients. None had a significant increase in obstruction while undergoing irradiation. All of the patients were managed conservatively. A number of patients judged to have more severe urinary outlet obstruction were treated by endocrine therapy before irradiation. The obstruction was alleviated and none had post-irradiation incontinence. The addition of endocrine therapy to irradiation also may improve tumor control and ~ u r v i v a l . ' ~ Accordingly, ~*~ a trial of endocrine therapy should be considered as the initial treatment for patients with moderately severe obstruction. Transurethral prostatectomy could be reserved for patients who have tumor refractory to endocrine therapy. After irradiation every effort also should be made to avoid urethral trauma. In our experience incontinence was more frequent and more severe if transurethral prostatectomy was done after irradiation compared to before irradiation. Again, a trial of endocrine therapy should be considered as the initial treatment of urinary outlet obstruction from recurrent cancer.
3 Mos.
1 Yr.
3 Yrs.
3 4 2
6 1
6 1 2
2
PROSTATE CANCER: POST-IRRADIATION INCONTINENCE Assistance w i t h t h i s s t u d y w a s provided b y Drs. B a s s a m Bejjani, H e n r y B o d n e r , E u g e n e M. B r o t h , C h i n g Chiang, J e r r y S. G a r r e t t , H a r v e y W. Goldberg, A b r a h a m M. B. Goldstein, R o b e r t L. Gray, Vincent; Gualtieri, M a r c e l I. Horowitz, J a c k A. Jaffe, R o n a l d J. K a p l a n , Floyd A. K a t s k e , S t e p h e n Kugler, P h i l i p K u r z n e r , G a r y Lieskovsky, Louis J. Lombardo, J r . , R o b e r t Michaels, D o n a l d Motzkin, R i c h a r d C. Onofrio, R e n e O s m a n , S a n f o r d L. Polse, S t a n l e y C. Ross, R o b e r t Saffian, Isadore R. Schlossberg, R i c h a r d A. Shapiro, L e o n a r d B. Skaist, D o n a l d G. S k i n n e r , J. B r a d l e y T a y l o r , A r t h u r V a t z a n d Harley Wishner. REFERENCES
1. Hanks, G. E.: Radical prostatectomy or radiation therapy for early prostate cancer. Two roads t o the same end. Cancer, 61: 2153, 1988. 2. Jewett, H. J.: Prostatic cancer: a personal view of the problem. J . Urol., 131: 845, 1984. 3. Lindner, A,, deKernion, J. B., Smith, R. B. and Katske, F. A.: Risk of urinary incontinence following radical prostatectomy. J . Urol., 129: 1007, 1983. 4. Paulson, D. F., Lin, G. H., Hinshaw, W., Stephani, S. and the UroOncology Research Group: Radical surgery versus radiotherapy for adenocarcinoma of the prostate. J . Urol., 128: 502, 1982. 5. Pilepich, M. V., Perez, C. A., Walz, B. J , and Zivnuska, F. R.: Complications of definitive radiotherapy for carcinoma of the prostate. Int. J. Rad. Oncol. Biol. Phys., 7: 1341, 1981. 6. Kaufman, J . J., Smith, R. B. and Raz, S.: Radiation therapy in carcinoma of t h e prostate: a contributing cause of urinary incontinence. J . Urol., 132: 998, 1984. 7. Perez, C. A., Ackerman, L. V., Silber, I. and Royce, R. K.: Radiation therapy in the treatment of localized carcinoma of the prostate. Preliminary report using 22-MeV photons. Cancer, 34: 1059, 1974. 8. Beahrs, 0 . H., Henson, D. E., Hutler, R. V. and Myers, M. H.: Manual for Staging of Cancer, 3rd ed. Philadelphia: J. B. Lippincott Co., chapt, 29, pp. 177-179, 1988. 9. Epstein, J . P.: T h e prostate and seminal vesicle. In: Diagnostic Surgical Pathology. Edited by Stephen S. Sternberg. New York: Raven Press, chapt. 41, pp. 1401-1409, 1989. 10. Hadley, H. R., Zimmern, P. E. and Raz, S.: The treatment of male urinary incontinence. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T . A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 72, pp. 26582679, 1986.
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11. Rudy, D. C., Woodside, J. R. and Crawford, E. D.: Urodynamic evaluation of incontinence in patients undergoing modified Campbell radical retropubic prostatectomy: a prospective study. J . Urol., 132: 708, 1984. 12. Glenn, J. F.: Surgical therapy of cancer of the prostate. In: Genitourinary Cancer. Edited by D. G. Skinner and J . B. deKernion. Philadelphia: W. B. Saunders Co., chapt. 18, pp. 344-354, 1978. 13. Igel, T . C., Barrett, D. M., Segura, J. W., Benson, R. C., Jr. and Rife, C. C.: Perioperative and postoperative complications from bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. J . Urol., 137: 1189, 1987. 14. Anscher, M. S. and Prosnitz, L. R.: Postoperative radiotherapy for patients with carcinoma of the prostate undergoing radical prostatectomy with positive surgical margins, seminal vesicle involvement and/or penetrationthrough the capsule. J. Urol., 138: 1407,1987. 15. Barrett, D. M. and Furlow, W. L.: Radical prostatectomy incontinence and the AS791 artificial urinary sphincter. J . Urol., 129: 528, 1983. 16. Middleton, R. G., Smith, J . A., Jr., Melzer, R. B. and Hamilton, P. E.: Patient survival and local recurrence rate following radical prostatectomy for prostatic carcinoma. J. Urol., 136: 422, 1986. 17. Skinner, D. G. and Lieskovsky, G.: Carcinoma of the prostate: an opinion on management of early stage disease with a commentary on the meaning of capsular penetration. J . Urol., 134: 1183, 1985. 18. Bagshaw, M. A,: Radiation therapy for cancer of the prostate. In: Genitourinary Cancer. Edited by D. G. Skinner and J . B. deKernion. Philadelphia: W. B. Saunders Co., chapt. 19, pp. 355379, 1978. 19. Pilepich, M. V., Asbell, S. O., Krall, J. M., Baerwald, W. H., Sause, W. T., Rubin, P., Emami, B. N. and Pidcock, G. M.: Correlation of radiotherapeutic parameters and treatment related morbidity-analysis of RTOG study 77-06. Int. J . Rad. Oncol. Biol. Phys., 3: 1007, 1987. 20. Green, N., Bodner, H., Broth, E., Chiang, C., Garrett, J., Goldstein, A., Goldberg, H., Gualtieri, V., Gray, R., Jaffe, J., Kaplan, R., Polse, S., Ross, S., Skaist, L., Treible, D., Vatz, A. a n d Wallack, H.: Improved control of bulky prostate carcinoma with sequential ; estrogen and radiation therapy. Int. J. Rad. Oncol. ~ i o l Phys., 10: 971, 1984. 21. Zagars, G. K., Johnson, D. E., Von Eschenbach, A. C. a n d Hussey, A. H.: Adjuvant estrogen following radiation therapy for stage C adenocarcinoma of the prostate: long-term results of a prospective randomized study. Int. J. Rad. Oncol. Biol. Phys., 14: 1085, 1988.
