Acute and late adverse events of LDR brachytherapy

3.6.1. Urinary toxicity

Almost all patients after LDR brachytherapy develop some kind of acute urinary symptoms, for example, urinary frequency, urgency, and occasional urge incontinence. These symptoms often peak at about 3 months after brachytherapy, subsequently gradually decline over the ensuing 3 to 6 months, and resolve with in 1 year (71). Most patients benefit with the use of an a-blocker. However, Brown et al [71] reported that 22% of patients experienced persistent urinary symptoms even after 12 months.

Acute urinary retention (AUR) is a common complication of modern brachytherapy, but can occur immediately after LDR brachytherapy. Crook et al. [72] demonstrated on the basis of a multivariate analysis that larger prostate volumes and prior hormone therapy were each independent predictors of AUR. AUR should be managed by intermittent or continuous bladder drainage. If AUR persists more than a few days, clean intermittent self-catheterization is preferred to continuous drainage by a Foley catheter. The use of transurethral incision of prostate should be avoided in the first 6 months, but if retention persists, transurethral incision of prostate or minimal TURP may be considered, recognizing the risk of urinary incontinence after these procedures [73-75].

3.6.2. Rectal toxicity

Grade 2 rectal toxicity symptoms, which manifest as rectal bleeding or increased mucous discharge, occur in 2 to 10% of patients, nearly always manifests between 6 and 18 months of implantation [76]. It is partly related to rectal dose and its volume exposed to a particular dose. The incidence of grade 3 or 4 rectal toxicity, which symptoms manifest rectal ulceration or fistula, is unusual (< 1.0%), providing that the volume of rectal wall receiving the prescription dose is kept below 0.5 cc on day 0 or 1 cc on day 30 dosimetry [77]. Most cases of rectal bleeding do not progress to rectal ulceration or fistula and are self-limited in nature. However, healing is typically slow. With the ineffectiveness of medical therapies, more invasive therapies with argon plasma coagulation or topical formalin have been highly effective therapy for rectal bleeding [78]. Invasive therapies, however, might exacerbate radiation damage, so they should be undertaken with caution. Rectal wall biopsy in the course of evaluation for rectal toxicity should avoid as much as possible because it may result in the development of rectal ulceration or fistula.

3.6.3. Sexual dysfunction

Erectile impotence occurs from 20% to 80% after implantation. According to Zelefsky et al [79], whereas the incidence of impotence at 2 years after implantation was 21%, the rate increased to 42% at 5 years after. Merrick et al. [80] reported that there is a strong correlation between radiation-induced impotence and the dose to the penile bulb and proximal penis. They recommend that with day 0 dosimetric evaluation, the minimum dose delivered to 50% and 25% of the bulb should be maintained below 40% and 60% of prescribed minimum peripheral dose, respectively, whereas the minimum dose delivered to 50% and 25% of the crura should be maintained below 40% and 28% of prescribed minimum peripheral dose, respectively, to maximize posttreatment potency.

Several reports suggest that sildenafil citrate have good response to impotence after im-plantation[81, 82]. Potters et al. [83] reported that the addition of neoadjuvant androgen deprivation had a significant impact on the potency preservation rate after implantation.

The response to sildenafil was significantly better in those patients not treated with neo-adjuvant ADT.

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