Is Previous Transurethral Resection of the Prostate a Contraindication to Brachytherapy

Reviewer: Ryan Smith, MD
OncoLink
Last Modified: October 7, 2002

Presenter: Moran, Brian
Presenter's Affiliation: Chicago Prostate Cancer Center
Type of Session: Scientific

Background

Transurethral resection of the prostate (TURP) was the most common GU procedure performed in the 1980s and 1990s. The reported incontinence rate from this procedure is 1-2%. In those patients undergoing brachytherapy as treatment for prostate cancer, the incontinence rate has been reported 7% to 24%. However, these reports were when a uniform dose was given to the entire gland, with no concern given to the peri-urethral area-which dictates the development of incontinence.

Materials and Methods

This report is based on 118 patients who had undergone prior TURP, then treated with brachytherapy
All patients were administered the UCLA Prostate Index to assess their urinary function after brachytherapy implant
Median time of TURP prior to implant was 6.5 years
Median follow up was 2 years
Dose plan was done to deliberately avoid central area of the urethra, which is the area at risk in developing incontinence
Mean pretreatment PSA was 9.5
60% were treated with I-125, 40% with Pd-103
Mean AUA score prior to implant was 7.75

Results

Approximately 60% of the patients retuned the survey
UCLA score of urinary function revealed a mean score of 83, which corresponds to little or no problems with urinary function
UCLA score of urinary bother revealed a mean score of 82, which corresponds to little to no bother
On multivariate analysis, pretreatment AUA score was the only factor significant in determining post implant function. There was no relationship between type or total activity of the implant.

Author's Conclusions

Patients with AUA scores of less than 8 that underwent implant after a prior TURP had less symptoms of problems with urinary function and urinary bother.
If careful planning is used, brachytherapy can be done in patients with prior TURP.
If TURP defect is large and the prostate small, those patients should not be implanted

Clinical/Scientific Implications

Prior TURP has been a relative contraindication for brachytherapy implant as treatment for prostate cancer, mainly due to reported adverse effects on urinary continence and the development of urinary stricture. This study reports that brachytherapy can be done in these patients with prior TURP if careful planning is done and if they have low pretreatment AUA scores. However, this careful planning involved sparing the periurethral area, which likely does spare patients incontinence, but which may also give tumor inadequate dose. Also, the data presented reveals that over 20% still leaked urine everyday and over 15% still had problems with overall urinary bother. This is not reflected when the data is presented as a mean UCLA urinary function/bother score. This is in a group in which only 60% returned the survey, which could greatly skew the data in either direction. Also, there is no mention of the development of urinary stricture which is at least as large of a concern as incontinence. With all of these factors considered and the continued low incidence of incontinence reported with external beam radiation therapy, TURP should likely remain a relative contraindication to prostate brachytherapy.

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