Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults and the risk of developing urinary incontinence (UI) [1]. Radiation-induced strictures in prostate cancer therapy most commonly occur in the bulbomembranous region in patients elected for primary RT and at the vesicourethral anastomosis (VUA) in patients elected for salvage (sRT) or neoadjuvant RT [2]. The objective of this review is to evaluate the risk of radiation-induced disease, namely Urinary Incontinence, VUA strictures (VUAs) and hemorrhagic radiation cystitis after sRT and educate urologists in clinical practice to take into account in their future choices about the problems they will have to deal with.

We performed a retrospective analysis of patients at our institution, from a single urologist's consultation who underwent sRT between 2008 and 2023. Radical prostatectomies were performed between 2006 and 2022. We included men who had sRT, with at least a 2-year follow-up. Data collected were based on routine clinical follow-up. Their responses were recorded in the clinical notes. UI was defined as the presence of any reported leakage. VUA and urethral stricture status were based on cystoscopic findings, with the need for cystoscopy based on lower urinary tract symptoms. All patients with transient complaints of UI or dysuria after sRT in the context of probable bladder hyperactivity or bladder neck contracture that resolved with drug treatment (anticholinergics or alpha-blockers) were considered as having no complications. For UI and VUAs/urethral stricture, patients were excluded from the analysis if they had any of these problems prior to sRT.

From our cohort of patients undergoing sRT for biochemically recurrent prostate cancer after radical prostatectomy, only 81 were considered suitable for the study. The mean follow-up time after sRT was 94 months (range: 24 – 204 months). Urinary incontinence after sRT was reported in a total of 11 patients, 2 regained continence over time, and only 9 remained incontinent (11,1%). Within 4 years of completing treatment with sRT, 10 patients (12,3%) developed VUAs/urethral strictures. Late toxicity with hemorrhagic radiation cystitis was reported in 3 patients (3,7%), 2 of them had concomitant VUAs/urethral stricture.

In our original study, radiation-induced VUAs/urethral strictures disease was the most prevalent urinary complication of sRT. Chronic toxicity related to sRT can appear late after treatment, however, most urinary complications manifest within 4 years of therapy and can affect about a quarter of the men undergoing sRT.

This study may serve to well inform patients when they have to decide regarding sRT. According to our cohort review, sRT chronic toxicity reached 24,7% of the men.

[1] - Muise, A.; Pan, M.M.; Rose, B.; Buckley, J.C. Functional outcomes after prostate cancer treatment: A comparison between single and multiple modalities. Urol. Oncol. Semin. Orig. Investig. 2023, 41, 104.e1–104.e 9.
[2] - Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease by Joshua Sterling 1ORCID, Syed N. Rahman 1, Ajin Varghese 2, Javier C. Angulo 3ORCID and Dmitriy Nikolavsky. J. Clin. Med. 2023, 12(12), 3950;