Since the inception of the National Cancer Act and “War on Cancer” in 1971, there have been significant advances in the multimodality treatment for pelvic malignancies. Because of this the numbers of men and women living for long periods after their life-saving treatment is rapidly increasing. In fact, 14.5 million Americans with prior cancer were alive in 2014 and this number of cancer survivors will exceed 19 million in 2024. ¹

Over the last 4 decades there have been striking improvements in life-saving cancer therapies. While originally the focus was cancer cure, now as so many patients are living longer after treatment the emphasis is evolving to long-term quality of life for cancer survivors.

Primary pelvic malignancies make up almost 20% of all cancer. The improvement in outcomes is due to multimodal therapy including surgery, chemotherapy and radiation therapy (RT). Radiation therapy has played a significantly larger role in the treatment of these patients with greater than 50% of patients suffering from prostate, cervical, colorectal and bladder cancer receiving radiation as part of their therapy.

Radiation’s therapeutic effect is primarily through cellular DNA damage. Toxicity from RT has 2 time components: acute–arising during active treatment–and late–ones that present and persist for long periods of time after primary treatment. While the acute side effects often resolve within 1 to 2 months, it is the late ones that urologists are saddled with caring for because of the improvements in survival. These may include incontinence, urinary retention, bladder overactivity, pain, fistula, hemorrhagic cystitis and urethral and ureteral strictures leading to significant morbidity. In many cases, patients have the unsavory situation of experiencing more than one of these for many years after their life-saving therapy. ²

While the true incidence of side effects after RT is unknown, Elliott and his group outlined estimates of these rates based on the review of SEER data and Medicare data (see table). ³

A vexing component of this problem for the clinician is that many of these late side effects may arise years and even decades later. This is particularly relevant to prostate cancer survivors who develop end-stage bladders, pubic symphysis fistula and pubic bone osteomyelitis an average of 8 to 10 years after therapy. ⁴

Although it would be ideal to offer reconstructive options for all cases of pelvic radiation injury, in many cases these necessitate urinary diversion with or without cystectomy. Situations where the bladder is not salvageable are those with large fistula to the rectum or fistula in women, which often involve the bladder, vagina and rectum, especially when associated with extensive necrosis (fig. 1). Other devastating examples of unsalvageable high grade RT injury include symphysis fistula (fig. 2) and the predictable osteomyelitis of the pubic bone, which are often associated with severe necrosis of the prostatic fossa and bladder floor with very little viable tissue to repair.

Figure 1. A patient with extensive necrosis in prostate with involvement of bladder neck.

A key element in evaluating these injuries is the condition of the bladder. Even if a fistula can be repaired, if the bladder has severe radiation cystitis and contraction patients may remain crippled by their urinary symptoms even if the fistula is successfully closed. Often in these situations patients will have multiple side effects from the RT including fistula, concomitant ureteral stricture and incontinence. We have found that when multiple complications are present patients are often best served by urinary diversion. Another situation where upfront urinary diversion should be presented to patients as an option is when an artificial urinary sphincter will be needed after lower urinary tract reconstruction. A common problem would be a recalcitrant bladder neck contraction after radical prostatectomy followed by adjuvant pelvic radiotherapy. If this is not amendable to robotic repair from the pelvis and perineal repair is performed with bulbar mobilization, patients often will end with total incontinence. In this circumstance patients are at very high risk for artificial urinary sphincter (AUS) erosion, even if the AUS is placed in a transcorporal fashion and staged 3 to 12 months after the initial repair. It is important to explain the unhappy scenario of successful repair followed by a period of total incontinence followed by AUS placement followed by AUS explantation for erosion and ending up with a suprapubic tube and eventually urinary diversion. Some patients when confronting this long path often elect for upfront urinary diversion. ⁵

Figure 2. Symphysis fistula in a patient after prostate cancer radiotherapy.

Many of these patients have suffered for years with these chronic illnesses, and when planning for urinary diversion due to severe side effects of RT it is paramount to optimize all of the modifiable surgical risk factors before surgery. Diabetes should be well-controlled and patients should not be in a catabolic state with low albumin with optimized comorbidities for surgery. In men undergoing urinary diversion after prostate cancer pelvic RT we found that the patients were often older (mean age 71 years), presented 8 years after radiotherapy and had a rate of death and major complications (Clavien–Dindo complication 3 or greater) of 5% and 36%, respectively. ⁶ A similar death rate and major complication rate were noted in women undergoing urinary diversion after pelvic RT for gynecological malignancy. ⁷ Some patients are so ill on presentation that they may require outside-the-box strategies such as concomitant placement of colostomy and colon conduit or switching an existing colostomy to a urinary conduit and creating a new colostomy more proximally. These strategies have the advantage of eliminating a bowel anastomosis, which may not heal in a severely debilitated patient, leading to disaster.

There are significant gaps in our knowledge about high grade RT complications. It is unclear if genetics, environment or patient factors predispose patients to high grade complications, and it can be at times perplexing to understand why some patients develop these complications and others with the same radiation dose barely have any visible tissue effect. One could imagine a future when genetic or epigenetic milieu may be combined with tumor and patient factors to predict the optimal treatment for the tumor and the risk of high grade RT complications in the individual patient.