Incidence and risk factors

After radiotherapy for cervical carcinoma

As for proctitis, the association brachytherapy-surgery induces a low rate of severe genito-urinary complications: around 1 to 5%104-106. In 441 patients, Gerbaulet105 found respectively 2.7% and 4.6% of severe urinary complications for stages I and II. Perez107,108, comparing preoperative radiation and radiation alone in two trials, reported no significant difference: 4.1% vs 5.7%, and 3% to 10 % according to the stage vs 3%.

Using radiation alone, the rate of severe complications ranges from 2 to 5 % 106,109-111,189 (Table 1). For Eifel111, in 1784 patients with FIGO stage IB cervical carcinoma, the risk of developing major urinary tract complications was approximately 0.7% per year during the first 3 years, and around 0.25% per year for at least 25 years.

As for intestinal complications, old age is not a risk factor for urinary complications97'99'111'121, whereas prior abdominal surgery is one96,111. Stage is a risk factor too127. The correlation between radiation dose and bladder complication is well documented96'98'109'122'124'125. For Logsdon125, major pelvic complications significantly increase when the dose of external radiation is superior to 52 Gy. Montana190 reported 3% of severe cystitis for patients receiving less than 50 Gy to the bladder, versus 12 % for doses superior to 80 Gy, with a significant relationship between bladder dose and severity of complication. Sinistrero124 found a correlation between bladder dose and severity of cystitis too. Using low dose rate brachytherapy, bladder complications are more frequent with the higher dose rates109,129,130. Perez109 reported 2.9% of grade 2-3 morbidity with dose rate inferior to 0.8 Gy/h, and 6.1% with higher dose rates.

After radiotherapy for prostate carcinoma

Lawton98 reported 2.6% of grade 3 or higher cystitis, with 0.4% of grade 4 (RTOG scoring). Grade 3 or higher urethral stricture was the most common urinary complication (4.6%); hematuria was present in 3% of the patients. In modern series, severe late bladder morbidity is inferior to 5 %131-

134,136,191

After radiotherapy for bladder cancer

Bladder complications are more frequent; the volume of bladder irradiated is greater, and the presence of the tumour may make the bladder more sensitive to radiotherapy. The risk of grade 3 or higher complication is ranged from 2 to 30%; using chemotherapy and radiotherapy, concomitant or sequential, the rates seem similar190.

For Emami, after radiotherapy for pelvic malignancies, the TD5/5 for whole and 2/3 irradiation are 65 and 80 Gy; the TD 50/5 for whole and 2/3 irradiation are estimated at 80 and 85 Gy126. These last data are speculative because the entire bladder rarely receives these doses. For Marks190, these doses are lower: he estimates the complication rate to be 5-10% with doses of 50-65 Gy delivered to 1/3 of the bladder, or with doses of 65-75 Gy to less than 20% of the bladder. Urethral strictures occur in less than 5% with doses between 60-70 Gy without a prior trans urethral resection (TURP); if a TURP was performed before radiotherapy, urethral strictures occur in 5 to 15%190.

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