Multimodality-based care for pelvic malignancy has significantly improved survival over the last several decades. This has led to an exponential increase in the number of cancer survivors in the US, from 3.7 million in 1975 to almost 20 million today. This number is expected to reach over 26 million by 2040. Furthermore, over one-third of these malignancies involve urology organs, or those affecting urology organs such as the prostate, bladder, rectum, uterus, and cervix, making this an important issue for all practicing urologists.¹

Radiation therapy is a key component to the successful treatment and cure of these cancers. As we see patients living longer, we will undoubtedly see more long-term side effects of this lifesaving therapy long after the cancer is defeated. A recent report from the University of Chicago shows that the median time to development of troublesome hematuria after radiation therapy for prostate cancer was 39 months (IQR 22-65), over 3 years from the treatment.² Similarly, men and women that develop fistula disease and bone infection as a result of radiation therapy present over 8 years after their primary treatment.³

We can confidently state that we are seeing a phenomenon we refer to as “survivorship length bias” where patients with these primary malignancies now are living much longer than they had in the past, therefore unveiling potential long-term side effects of their lifesaving therapy long after the treatment is completed!⁴

The bladder is a classic organ at risk for exposure to lifesaving radiation therapy and may manifest several problems after exposure. We have termed these the “terrible 5,” including: (1) the devastated outlet (which involves both incontinence and outlet stricture), (2) the hostile bladder (with overactivity, loss of storage capacity, and chronic pain from cystitis and contraction), (3) radiation cystitis (with recurrent life-threatening bleeding), (4) fistula disease (to the rectum or anteriorly to the pubic symphysis), and (5) damage to the upper tracts (resulting from obstruction of the lower genitourinary tract resulting in hydronephrosis and potential damage to the kidneys; Figure). There are many situations where any one of these 5 alone may need to be addressed surgically with cystectomy when serious, such as in the cases of recalcitrant transfusion–dependent radiation cystitis or rectourethral fistulas that are very large and not repairable.^5,6 However, we have found clinically that when patients present with 3 of the “terrible 5” that are grades 2-4 per the National Cancer Institute Common Terminology Criteria for Adverse Events,⁷ the damage to the primary organ is often so severe that the lower genitourinary tract is not repairable. Therefore, we began offering postradiation cystectomy with urinary diversion for these patients early in their course of treatment.

Pelvic exenterative surgery for postradiation damage historically had the reputation of being surgically challenging with poor long-term outcomes.⁸ However, our contemporary experience is that these operations, while challenging, can result in very good outcomes.⁹ In patients with pain as a key component to the end-stage bladder, almost all will be cured after removal of the radiated end-stage bladder.¹⁰ We also see significantly improved quality of life as outlined by the 12-Item Short Form Health Survey and other physiological indicators of overall health. The 12-Item Short Form Health Survey includes 6 questions on physical functioning and 6 questions on mental health. These are almost uniformly improved in those patients who have very low score prior to the exenterative surgery.¹¹ Therefore, we feel extirpative surgery should be offered to patients with acceptable short-term risk and excellent long-term quality of life improvement.

The need for bladder removal with urinary diversion for the end-stage radiated bladder will undoubtedly increase in the next decade as our patients live longer and therapy continues to improve. While this is a very large operation with potential lifestyle changes for the patient, it can be done safely and with good outcomes in the long term. Additionally, quality of life is significantly impacted after treatment of the potential myriad of complications from radiation. If patient satisfaction can be considered one of the primary outcomes for any surgical intervention, our patient testimonials must be considered. Patients often tell us when we see them for follow-up, “My only regret…is I wish I had done this many years earlier!”