Urodynamic changes at 18 months post-therapy in patients treated with external beam radiotherapy for prostate carcinoma

Which characteristics are associated with changes in medication status for lower urinary tract symptoms among patients with prostate cancer receiving external beam radiotherapy?

Background

We clarified the predictive factors for changes in the status of medications for lower urinary tract symptoms (LUTS) 2 years after local radiotherapy for nonmetastatic prostate cancer.

Materials and methods

We retrospectively included patients who underwent local external radiotherapy for nonmetastatic prostate cancer in 8 institutions between April 2001 and March 2016. Patients were divided into the medication and no-medication group based on the use of drugs for LUTS before radiotherapy. We defined improvement of LUTS as when the patient did not require medication for LUTS at 24 months after radiotherapy in the medication group and as deterioration when medication was required in the no-medication group. Logistic regression analysis was used to evaluate predictive factors for changes in medication status.

Results

Altogether, 505 patients were divided into a no-medication group (n = 352) and a medication group (n = 153). The number of patients with deterioration and improvement in LUTS was 49 (14%) and 36 (23%), respectively. In the multivariate analysis, the predictive variables for deterioration were the International Prostate Symptom Score (≥8; odds ratio [OR], 2.21; p = 0.014) and the biopsy Gleason score (≤3 + 4 = 7; OR, 2.430; p = 0.008) in the no-medication group, whereas those for improvement were age (<75 years old; OR, 5.81; p = 0.002), the quality of life score (<3; OR, 3.15; p = 0.028), and a positive biopsy core rate (≥50%; OR, 2.530; p = 0.027) in the medication group.

Conclusions

These predictive factors for changes in the status of medications for LUTS at 2 years after external radiotherapy may help determine the definitive therapy for nonmetastatic prostate cancer.

Impact of a radical prostatectomy on the urodynamic results of prostate cancer patients treated with intensity modulated radiation therapy

INTRODUCTION AND OBJECTIVES

To evaluate the effect of radical prostatectomy and age on urodynamics before and after intensity-modulated radiation therapy administered to prostate cancer patients.

MATERIALS AND METHODS

The sample consisted of 40 prostate cancer patients, 22 of whom had undergone a radical prostatectomy. Urodynamic parameters before and after an average of 4.2 months of radiotherapy were measured and compared. External radiotherapy was administered via Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Radiation Therapy (IMRT) techniques.

RESULTS

Uroflowmetry presented no significant parameters. In the case of Cystomanometry, the data did not show an increase in secondary stress urinary incontinence, although there is 7 percent increase in urge urinary incontinence. There were statistically significant changes in reduced bladder capacity with a strong desire to void, with an urge to void and also in the detrusor pressure with a normal desire to void. Furthermore, pressure/flow analysis revealed a statistically significant reduction of residual urine volume.

CONCLUSIONS

The effect of prostatectomy and age varies according to the evolution of urodynamics. There was a significant reduction in terms of residual urine volume and detrusor pressure with a normal desire to void in patients without a prostatectomy and in those under 75 years old. In addition to an increase in urge incontinence, there was also a significant worsening of the bladder filling urodynamics and a decrease in the cystomanometric bladder capacity with a strong desire and an urge to void. None of these were modified by age or prostatectomy.

Management of Lower Urinary Tract Symptoms after Prostate Radiation

PURPOSE OF REVIEW

To present urologists with guidance on how to approach and manage lower urinary tract symptoms (LUTS) in patients who have undergone radiation therapy (RT) for prostate cancer.

RECENT FINDINGS

There are few studies that specifically examine treatment approaches for LUTS in patients who have undergone prostate cancer RT. LUTS after prostate RT are unique when compared to de novo LUTS. Understanding these distinctions is important for urologists' practice as well as patients' quality of life. Discussion of the risks and management of post-RT LUTS should be included in the shared decision-making process when counseling patients on various treatment options for prostate cancer. Further studies evaluating treatments for storage and voiding symptoms after RT are needed to help guide future care.

Assessment of Dysfunction in the Urinary System as Well as Comfort in the Life of Women during and after Combination Therapy Due to Ovarian and Endometrial Cancer Based on the SWL, II-Q7 and UDI-6 Scales

This work aimed to assess the influence of oncological combination therapy that was done on endometrial or ovarian cancer and how the urinary system is influenced as well as the quality of life in comparison to a group of female patients after the removal of the uterus with appendages due to endometrial cancer, which did not require the supplementation of therapy after operative treatment. The study included 87 patients with endometrial cancer, where, after the removal of the uterus, there was no need for conducting adjuvant therapy (C), as well as 92 female patients with endometrial cancer or 38 patients with ovarian cancer in whom combination therapy was conducted (group A, B). The assessment of the quality of life was conducted using the questionnaires: Satisfaction Life Scale (SWLS), Incontinence Impact Questionnaire, Short Form (IIQ-7), and Urogenital Distress Inventory (UDI-6) for three, six, nine, and 12 months after the conclusion of oncological treatment. It was observed that there was a statistically significant decrease in the quality of life in female patients who underwent combination therapy in comparison to a group in whose treatment only included surgery (p < 0.05). The risk of developing urinary incontinence increases alongside an increase in the scope of the operation and in the case of supplementing treatment with brachytherapy in comparison to chemotherapy.

Can radiation-induced lower urinary tract disease be ameliorated in patients treated for pelvic organ cancer: ICI-RS 2019?

Aims

This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies.

Methods

The topic was discussed at the 2019 meeting of the International Consultation on Incontinence―Research Society during a “think tank” session and is summarized in the present article.

Results

RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation‐associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed.

Conclusions

We conclude that RT‐induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.

Long Term Patient Reported Urinary Function Following External Beam Radiotherapy for Prostate Cancer

INTRODUCTION

This study reports long-term patient reported urinary function and urinary-related quality of life (uQoL) after external beam radiotherapy (EBRT) for localized prostate cancer.

METHODS

574 men underwent definitive prostate EBRT to 70-78 Gy±androgen deprivation therapy between 2000 and 2009. The median follow-up from EBRT was 44 months. Patients were evaluated at baseline (pre-EBRT) and at intervals post-treatment using the International Prostate Symptom Score (IPSS) instrument.

RESULTS

Patients with mild IPSS at baseline (total 0-7) reported median total scores of 3, 4 and 3 at baseline, 6 and 48 months respectively post-EBRT. For patients with moderate IPSS at baseline (total 8-19), median total IPSS was 12 at baseline and 9 at both 6 and 48 months. For the severe IPSS group at baseline (total 20-35), the median total IPSS was 24, 12 and 14 at baseline, 6 and 48 months post-EBRT. The cumulative risk of persistent IPSS increase (greater than 5 points above baseline) at 48 months was 16%, 10% and 6% for patients with mild, moderate and severe baseline IPSS respectively. 94%, 54% and 11% of patients with mild, moderate and severe baseline IPSS reported good uQoL at baseline respectively, with these proportions increasing to 95%, 83% and 69% at 48 months.

CONCLUSION

Urinary symptoms and uQoL as measured by the IPSS instrument remained stable or improved for the majority of men after definitive EBRT with or without ADT for prostate cancer. This was especially notable for the group of men with worse baseline symptoms or uQoL, with risk of persistent worsening of urinary symptoms decreasing with higher baseline IPSS category. Understanding the expected pattern of urinary symptoms and related uQoL in the months and years following EBRT taking into account baseline urinary function is highly valuable for counselling men as part of the therapeutic decision-making process.

Modeling Urinary Dysfunction After External Beam Radiation Therapy of the Prostate Using Bladder Dose-Surface Maps: Evidence of Spatially Variable Response of the Bladder Surface

PURPOSE

We assessed the association of the spatial distribution of dose to the bladder surface, described using dose-surface maps, with the risk of urinary dysfunction.

METHODS AND MATERIALS

The bladder dose-surface maps of 754 participants from the TROG 03.04-RADAR trial were generated from the volumetric data by virtually cutting the bladder at the sagittal slice, intersecting the bladder center-of-mass through to the bladder posterior and projecting the dose information on a 2-dimensional plane. Pixelwise dose comparisons were performed between patients with and without symptoms (dysuria, hematuria, incontinence, and an International Prostate Symptom Score increase of ≥10 [ΔIPSS10]). The results with and without permutation-based multiple-comparison adjustments are reported. The pixelwise multivariate analysis findings (peak-event model for dysuria, hematuria, and ΔIPSS10; event-count model for incontinence), with adjustments for clinical factors, are also reported.

RESULTS

The associations of the spatially specific dose measures to urinary dysfunction were dependent on the presence of specific symptoms. The doses received by the anteroinferior and, to lesser extent, posterosuperior surface of the bladder had the strongest relationship with the incidence of dysuria, hematuria, and ΔIPSS10, both with and without adjustment for clinical factors. For the doses to the posteroinferior region corresponding to the area of the trigone, the only symptom with significance was incontinence.

CONCLUSIONS

A spatially variable response of the bladder surface to the dose was found for symptoms of urinary dysfunction. Limiting the dose extending anteriorly might help reduce the risk of urinary dysfunction.

Can filling phase urodynamic parameters predict the success of the bulbar artificial urinary sphincter in treating post-prostatectomy incontinence?

OBJECTIVE

To evaluate whether filling phase urodynamic parameters can predict the success of the artificial urinary sphincter (AUS) in treating post-prostatectomy incontinence (PPI).

MATERIALS AND METHODS

We reviewed the pre-AUS urodynamics of 99 patients with PPI at two tertiary referral centers. We documented the peak DO pressure (P_det ), capacity, and compliance (C). We defined success as patient-reported continence or only using one safety pad. Patients' perception of improvement was assessed using the PGI-I score.

RESULTS

Sixty-eight percent (n = 68) of patients had a successful outcome. The mean compliance for the "success" and "failure" group was 112.3 mL/cmH₂ O (±119.7) and 34.1 mL/cmH₂ O (±36.2), respectively. Fifty-five percent (17/31) of patients in the "failure" group demonstrated DO(P_det  = 36.2 ± 18.2 cmH₂ O) compared to 18% (12/68) in the success group. The differences between the two groups in P_det and compliance were statistically significant (all P < 0.01). There was, however, no statistical difference between the mean cystometric capacities of patients in the two outcome groups. Thirteen out of 18 (72%) patients who had radiotherapy had a poor outcome ("success" group only 15% [9/59]). These results were used to develop a nomogram for the probability of AUS success. A good inverse correlation (r = -0.65) was demonstrated between the probability of AUS success as deduced from the nomogram and PGI-I score post-AUS implantation CONCLUSION: Compliance and P_det are predictors of outcome following AUS implantation for PPI. We have developed and internally validated a nomogram that may be used to determine an individualized likelihood of AUS success. This nomogram may be used as a counseling tool to objectively set realistic expectations of continence post-AUS implantation.

Dosimetry, clinical factors and medication intake influencing urinary symptoms after prostate radiotherapy: An analysis of data from the RADAR prostate radiotherapy trial

PURPOSE/OBJECTIVE

To identify dosimetry, clinical factors and medication intake impacting urinary symptoms after prostate radiotherapy.

MATERIAL AND METHODS

Data describing clinical factors and bladder dosimetry (reduced with principal component (PC) analysis) for 754 patients treated with external beam radiotherapy accrued by TROG 03.04 RADAR prostate radiotherapy trial were available for analysis. Urinary symptoms (frequency, incontinence, dysuria and haematuria) were prospectively assessed using LENT-SOMA to a median of 72months. The endpoints assessed were prevalence (grade ⩾1) at the end of radiotherapy (representing acute symptoms), at 18-, 36- and 54-month follow-ups (representing late symptoms) and peak late incidence including only grade ⩾2. Impact of factors was assessed using multivariate logistic regression models with correction for over-optimism.

RESULTS

Baseline symptoms, non-insulin dependent diabetes mellitus, age and PC1 (correlated to the mean dose) impact symptoms at >1 timepoints. Associations at a single timepoint were found for cerebrovascular condition, ECOG status and non-steroidal anti-inflammatory drug intake. Peak incidence analysis shows the impact of baseline, bowel and cerebrovascular condition and smoking status.

CONCLUSIONS

The prevalence and incidence analysis provide a complementary view for urinary symptom prediction. Sustained impacts across time points were found for several factors while some associations were not repeated at different time points suggesting poorer or transient impact.

The evidence for urodynamic investigation of patients with symptoms of urinary incontinence

Urodynamic studies are the gold standard to objectively diagnose dysfunction of the lower urinary tract. The widely available evidence for the clinical relevance is, however, fragmented. This article summarizes the published knowledge supporting the use of urodynamic studies in urinary incontinence in female, male and frail patients, as well as patients with relevant neurological disease. Five technological innovations are discussed briefly. Standard urodynamic cystometry can, on the basis of a solid body of evidence, objectively unveil the entire function of the lower urinary tract in all patients with urinary incontinence, regardless of the patients' perception of (ab-)normality of signs and or symptoms.

Short-term Effect of Radical Hysterectomy with or without Adjuvant Radiation Therapy on Urodynamic Parameters in Patients with Uterine Cervical Cancer

Purpose

Lower urinary tract dysfunction is the most common complication after radical pelvic surgery. The aims of this study were to assess the effect of radical hysterectomy (RH) on the storage function of the lower urinary tract and to evaluate the impact of radiation therapy (RT) on postoperative urodynamic parameters.

Methods

This was a retrospective review of preoperative and postoperative urodynamic variables, which were prospectively collected. All women from 2006 to 2008, who underwent RH for uterine cervical cancer with a stage of 1A to 2B with or without adjuvant RT were enrolled. All patients were divided into two groups: group 1, without RT, and group 2, with adjuvant RT. Urodynamic studies were performed before, 10 days after, and 6 months after RH.

Results

A total of 42 patients with a mean (±standard error) age of 51.9 (±12.3) years were analyzed. There were no significant differences in age, body mass index or clinical stage between the two groups. On the 10th postoperative day, all parameters were decreased except postvoid residual volume. In comparison with group 2 (n=14), group 1 (n=28) showed a significant increase in bladder compliance. At 6 months postoperatively, bladder compliance in group 1 had increased four times or more compared with that on postoperative 10 days. However, it had increased only 2.5 times in group 2 at the same time point (P<0.001).

Conclusions

The results of our study suggest that adjuvant RT after RH might result in a deterioration of bladder compliance. It is highly suggested that practitioners pay attention to low bladder compliance, especially in patients who have adjuvant RT after RH.