Pelvic radiotherapy for urogynaecological and colonic malignancies has acute and chronic effects on the urinary tract. Radiation induced damage causes tissue atrophy and fibrosis, leading to urinary tract dysfunction. Tissue ischaemia poses a significant management challenge for reconstructive surgeons, with poor viability of both urological and bowel systems. We examined the urological sequelae of radiotherapy, the types of reconstructive urological surgery (RUS) required, and functional outcomes in our cohort of patients.

A retrospective review was performed of all radiotherapy patients who underwent RUS, at a national referral centre between 2015-2017. Details including time from radiotherapy, pre-operative assessments, type of surgery performed and functional outcome were analysed.

27 patients were identified (3 men; 24 women, age 59 (27-83) yrs). The primary malignancy was cervical (19), rectal (5), urethral (1), vaginal (1) and pelvic sarcoma (1). The mean time between radiation and primary RUS was 8 years. All patients had videourodynamic study, CT urography and MR small bowel protocol to assess suitability for reconstruction. Primary dysfunction and RUS performed is shown on Table 1. 8/13 ureteric strictures were bilateral. Of the fistulae, 3 were vesicovaginal, one was neobladder to vagina. A total of 39 procedures was performed on 27 patients, and further revision surgery was required in 5/27 (19%) patients. 12 patients had renal impairment pre-operatively (mean GFR was 53mls/min), but GFR was preserved in all patients subsequent to surgery. Two patients had continued incontinence post-operatively, one after colposuspension, and another after clam ileocystoplasty, who both await further treatment. Two patients developed bowel obstruction; one required further laparotomy and a temporary ileostomy formation, and there was one small bowel fistula. One patient developed a DVT and pulmonary embolus.

The mean interval between radiotherapy and primary urological reconstruction surgery in our patients was 8 years. Literature suggest that bladder complications seem to develop at a steady pace for up to 25 years after radiotherapy. 39 procedures were performed on 27 patients to reconstruct complex ureteric strictures, bladder contractures and fistulae. Re-intervention and significant complications occurred in a third of cases.

This is a challenging cohort of patients, with significant compromise of the lower urinary tract and bowel function. A variety of major RUS is required for management. Post-operatively, urinary continence was achieved in the majority, and renal function was preserved. However, this was at a cost of significant re-intervention rate of 19% and significant morbidity in 14%. RUS in radiotherapy field should be performed in centres with experience