DOI: 10.1148/rg.24si045502
RadioGraphics 2004;24:S181-S194
© RSNA, 2004
LOWER GENITOURINARY TRACT IMAGING |
Complications of Prostate Cancer Treatment: Spectrum of Imaging Findings1
Corrie M. Yablon, MD,
Marc P. Banner, MD,
Parvati Ramchandani, MD and
Eric S. Rovner, MD
1 From the Departments of Radiology (C.M.Y., M.P.B., P.R.) and Surgery (Division of Urology) (M.P.B., E.S.R.), University of Pennsylvania Medical Center, One Silverstein, 3400 Spruce St, Philadelphia, PA 19104. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received January 30, 2004; revision requested March 3 and received April 28; accepted May 5. All authors have no financial relationships to disclose. Address correspondence to M.P.B. (e-mail: marc.banner@uphs.upenn.edu).
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Abstract
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The imaging appearances of prostate cancer are well described in the radiology literature, but little has been written about the detection and appearance of the complications of therapy for this disease. The most frequently used treatments for prostate cancer are surgical therapy (eg, radical retropubic prostatectomy, radical perineal prostatectomy), radiation therapy (eg, brachytherapy, external-beam radiation therapy, three-dimensional conformal radiation therapy, intensity-modulated radiation therapy), and cryoablative therapy, each of which may lead to complications with characteristic imaging appearances. Possible complications include lymphocele formation; injuries to the ureter, rectum, and urethra; prostatic necrosis; vesicourethral anastomotic leak and stricture; urethral stricture, necrosis, and fistula; radiation proctitis; transient bladder outlet obstruction; radiation-induced urethritis; urinary incontinence; and erectile dysfunction. With improvements in surgical techniques and advances in technology, complications of therapy for prostate cancer are decreasing but still occur with sufficient frequency to warrant familiarity on the part of radiologists. Knowledge of the diverse spectrum of these complications and their characteristic radiologic features facilitates prompt diagnosis and treatment.
© RSNA, 2004
Index Terms: Prostate neoplasms, 844.32, 844.33 • Prostate neoplasms, MR, 844.1214 • Prostate neoplasms, surgery, 844.458 • Prostate neoplasms, therapeutic radiology, 844.1299 • Prostate neoplasms, therapy • Radiations, injurious effects, complications of therapeutic radiology, 844.47
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- List the various treatment options for prostate cancer.
- Discuss the postoperative complications associated with different treatment modalities for prostate cancer.
- Describe the imaging findings associated with complications of prostate cancer therapy.
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Introduction
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In North American men, carcinoma of the prostate is both the second most commonly diagnosed malignancy and the second most common cause of cancer death (1). Although the imaging features of prostate cancer have been well described, little attention has been paid to the appearance of complications resulting from therapy for this disease. In this article, we discuss and illustrate the complications associated with the treatments most often used for localized and advanced prostate cancer: surgical therapy, radiation therapy, and cryoablative therapy.
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Surgical Therapy
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For carcinoma confined to the prostate, radical prostatectomy with a retropubic or perineal approach is the most frequently used treatment (2,3). During radical prostatectomy, the prostate and seminal vesicles are removed and an anastomosis is created between the bladder and the membranous urethra. An attempt is made to spare one or both of the neurovascular bundles surrounding the prostate to preserve potency in patients with clinically localized disease (2,4). Pelvic lymphadenectomy may precede both retropubic and perineal prostatectomy in patients with a prostate-specific antigen (PSA) level of more than 10 ng/mL and a Gleason score of at least 7 (2,4). Lymph nodes that are positive for carcinoma at histologic examination of frozen sections may alter therapeutic decisions with regard to subsequent prostatectomy.
Some surgical complications may be recognized intraoperatively and appropriately treated, whereas others may manifest in the postoperative period and have long-term consequences (5).
Intraoperative Complications
Rectal Injury.—
Inadvertent rectal injury is uncommon, occurring in up to 1% of cases (6). Predisposing factors include prior irradiation, rectal surgery, or transurethral resection of the prostate (6). A rectal injury that is recognized intraoperatively can be treated with primary closure if the patient has undergone adequate preoperative bowel preparation. Otherwise, a temporary diverting colostomy is necessary. Rectal injury that is not appreciated at surgery manifests in the postoperative period as a rectal fistula to the skin, bladder, or urethra (Fig 1).
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Figure 1. Rectal injury during radical retropubic prostatectomy. The patient presented 3 months after surgery with pneumaturia and fecaluria. Voiding cystourethrogram demonstrates a rectovesical fistula (solid arrow) that originates from the region of the vesicourethral anastomosis (VUA). R = rectum.
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Ureteral Injury.—
Ureteral injury during radical prostatectomy is uncommon (0.05%–1.6% of cases) (5). It can occur in conjunction with seminal vesicle dissection, extensive pelvic node dissection, or bladder neck reconstruction (Fig 2).
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Figure 2a. Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.
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Figure 2b. Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.
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Figure 2c. Intraoperative ureteral injury. (a) Pelvic computed tomographic (CT) scan shows a small urinoma (arrows) related to transection of the left ureter during pelvic lymph node dissection. The urinoma is seen adjacent to surgical clips. (b) Retrograde ureterogram shows contrast material extravasation (arrow) from the distal ureter into the urinoma. The obstructed left collecting system and ureter remain opacified from excretory urography performed the previous day. (c) Subsequent antegrade pyelogram demonstrates extravasation of contrast material at the site of ureteral transection (arrows), with no opacification of the distal ureter. The injury was surgically repaired and the ureter reimplanted into the bladder.
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Perioperative Complications
Lymphoceles develop in up to 61% of patients undergoing open pelvic lymph node dissection and 29% of patients undergoing laparoscopic pelvic lymph node dissection. However, only 2.3% of these lymphoceles are clinically important (Fig 3) (7). Most lymphoceles are asymptomatic and resolve spontaneously. Drainage or ablation may be necessary if lymphoceles are large (>5 cm), become infected, are associated with pain, or cause compression of adjacent structures (eg, ureter, urinary bladder, iliac veins).
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Figure 3. Postoperative lymphoceles. Pelvic CT scan demonstrates a small, right-sided lymphocele (arrow) and a large, bilobed left lymphocele (L) compressing the urinary bladder (B).
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Complications Related to the Bladder Drainage Catheter
A vesicourethral anastomosis (VUA) is created around a large-bore (18–22-F) Foley urethral catheter that is left in place for urinary drainage until the VUA has healed. This large catheter can incite stricture formation at the urethral meatus, fossa navicularis, distal penile urethra, or bulbar urethra (Fig 4). The catheter can also become encrusted. Encrustation may hamper balloon deflation and catheter removal. Broken-off calcific crusts can remain in the bladder and serve as a nidus for subsequent bladder stone formation (Fig 5). The prevalence of and risk factors for this complication are not known.
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Figure 4. Catheter-related urethral stricture. Retrograde urethrogram obtained 2 months after radical retrograde prostatectomy demonstrates a stricture in the fossa navicularis (arrow).
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Figure 5a. Encrusted bladder catheter. (a) Radiograph obtained 3 weeks after radical retrograde prostatectomy demonstrates a thin rim of peripheral calcification (arrows) on an inflated Foley catheter balloon within the urinary bladder. The tip of the catheter is also encrusted. Surgical clips are related to pelvic lymph node dissection. The balloon was deflated and the catheter uneventfully removed. (b) Radiograph of the pelvis obtained 9 months later shows a large bladder calculus that undoubtedly formed as a result of a nidus of calcific debris left behind when the Foley catheter was removed.
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Figure 5b. Encrusted bladder catheter. (a) Radiograph obtained 3 weeks after radical retrograde prostatectomy demonstrates a thin rim of peripheral calcification (arrows) on an inflated Foley catheter balloon within the urinary bladder. The tip of the catheter is also encrusted. Surgical clips are related to pelvic lymph node dissection. The balloon was deflated and the catheter uneventfully removed. (b) Radiograph of the pelvis obtained 9 months later shows a large bladder calculus that undoubtedly formed as a result of a nidus of calcific debris left behind when the Foley catheter was removed.
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Complications Related to VUA Creation
Anastomotic Leak.—
The optimal interval between surgery and Foley catheter removal has not been well established. A recent trend toward early catheter removal after 7 days may facilitate early bladder rehabilitation and decrease catheter-related discomfort (8). At our institution, voiding cystourethrography is performed approximately 10 days after surgery before anticipated catheter removal.
The expected appearance of the VUA has been previously described (9). Small, well-defined linear or arrowhead-shaped outpouchings of contrast material may be seen at the lateral aspect of the anastomosis, a finding that represents mucosal plication. Leaks tend to occur at the posterolateral aspect of the anastomosis, which is the portion that is deepest in the pelvis, the most tenuous, and the most difficult to reconstruct without undue suture tension (Fig 6) (9). Leaks may be large or small and usually have ill-defined margins. When contrast material extravasation is present at the initial imaging examination, the Foley catheter is left in place and imaging is repeated weekly until the extravasation resolves.
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Figure 6a. Anastomotic leak. (a) Voiding cystourethrogram obtained 10 days after radical retrograde prostatectomy demonstrates bilateral small, poorly marginated VUA leaks (arrows). (b) Voiding cystourethrogram obtained 10 days later shows that the leaks have resolved.
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Figure 6b. Anastomotic leak. (a) Voiding cystourethrogram obtained 10 days after radical retrograde prostatectomy demonstrates bilateral small, poorly marginated VUA leaks (arrows). (b) Voiding cystourethrogram obtained 10 days later shows that the leaks have resolved.
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Anastomotic Stricture.—
Strictures at the VUA have been reported in 0.5%–32% of cases (10). In a recent study, the prevalence was reported to be 4.8% (10). An anastomotic stricture may be related to surgical technique or postoperative fibrosis. Cigarette smoking, comorbidities associated with microvascular disease (eg, coronary artery disease, hypertension, diabetes mellitus), and hypertrophic wound healing may also play a role (10,11). Stricture development does not correlate with anastomotic leakage as long as the bladder drainage catheter remains in situ until anastomotic healing is documented (9,12).
Although transurethral balloon dilation is effective in approximately 60% of strictures (Fig 7) (13), the long-term durability of this technique is unknown. Often, direct vision endoscopic dilation or incision is required to effect long-term patency.
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Figure 7a. Anastomotic stricture. (a) Retrograde urethrogram obtained 3 months after radical retrograde prostatectomy demonstrates a tight stricture at the VUA (arrow). The stricture was successfully dilated with a high-pressure balloon catheter. (b) Retrograde urethrogram shows that the "waist" deformity of the almost completely inflated balloon at the stricture site (arrow) was effaced with continued inflation of the balloon (not shown).
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Figure 7b. Anastomotic stricture. (a) Retrograde urethrogram obtained 3 months after radical retrograde prostatectomy demonstrates a tight stricture at the VUA (arrow). The stricture was successfully dilated with a high-pressure balloon catheter. (b) Retrograde urethrogram shows that the "waist" deformity of the almost completely inflated balloon at the stricture site (arrow) was effaced with continued inflation of the balloon (not shown).
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Long-term Complications
Incontinence.—
The reported frequency and degree of urinary incontinence after radical prostatectomy vary widely and depend on the age and preoperative continence status of the patient and the expertise of the surgeon. Total urinary incontinence after radical prostatectomy occurs in 0%–17% of patients, and stress urinary incontinence occurs in 0%–35% (Fig 8) (5). Preservation of the functional urethral length has been found to be the most important factor for regaining postoperative continence (14,15). Other factors associated with regaining postoperative continence include preservation of the neurovascular bundles, improved surgical technique, lack of anastomotic stricture, and younger patient age (15). Oftentimes, however, anatomic factors encountered during surgery preclude the optimization of these factors.
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Figure 8. Penile clamp for postprostatectomy urinary incontinence. Anteroposterior radiograph of the pelvis in a patient with florid postprostatectomy urinary incontinence shows a Baumrucker clamp applied to the distal part of the penis.
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The two most common surgical treatments for postprostatectomy urinary incontinence are endoscopic injection of bulking agents into the periurethral tissues and implantation of an artificial urinary sphincter (AUS). In the former procedure, collagen or other bulking agents are endoscopically injected into the periurethral tissues near the VUA to increase bladder outlet resistance. Collagen deposits are easily seen on magnetic resonance (MR) images as well-circumscribed nodules that exhibit low to intermediate signal intensity on both T1- and T2-weighted images (Fig 9). Collagen can usually be differentiated from recurrent tumor near the VUA; the latter is usually isointense relative to the levator ani and obturator internus muscles on T1-weighted images and hyperintense on T2-weighted images (Fig 10) (16).
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Figure 9a. Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)
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Figure 9b. Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)
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Figure 9c. Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)
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Figure 9d. Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)
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Figure 9e. Collagen injections for postprostatectomy urinary incontinence. (a) Voiding cystourethrogram obtained after the patient voided demonstrates a round, smoothly marginated filling defect at the bladder base (arrow), a finding that represents injected collagen around the vesicourethral junction. (b) Transrectal ultrasonographic (US) image depicts the periurethral collagen deposit as a hypoechoic round mass. (c) Axial fast spin-echo T2-weighted MR image shows periurethral collagen as well-circumscribed masses with intermediate signal intensity posterolateral to the urethra (U). (d) Coronal fast spin-echo T2-weighted MR image shows two periurethral deposits of collagen with intermediate signal intensity just inferior to the VUA (arrow). The midline structure inferior to the collagen deposits is the penile bulb (P, base of corpus spongiosum). (e) On a contrast material-enhanced CT scan, the collagen appears as a hypoattenuating round nodule (arrow) within the avidly enhancing penile bulb. Periurethral collagen may have been inadvertently injected into the penile bulb. (Figs 9c-9e reprinted, with permission, from reference 16.)
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Figure 10a. Recurrent tumor after radical retropubic prostatectomy. (a) Axial spin-echo T1-weighted MR image obtained with an endorectal coil shows an oval mass (m) with intermediate signal intensity posterolateral to the bladder base. (b) Axial fast spin-echo T2-weighted MR image shows the mass (m) with high signal intensity. Recurrent prostatic adenocarcinoma was diagnosed at transrectal US-guided needle biopsy.
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Figure 10b. Recurrent tumor after radical retropubic prostatectomy. (a) Axial spin-echo T1-weighted MR image obtained with an endorectal coil shows an oval mass (m) with intermediate signal intensity posterolateral to the bladder base. (b) Axial fast spin-echo T2-weighted MR image shows the mass (m) with high signal intensity. Recurrent prostatic adenocarcinoma was diagnosed at transrectal US-guided needle biopsy.
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If one or more injections of periurethral bulking agents do not improve the patient’s continence status, an AUS may be implanted. For AUS implantation, a cuff is placed around the proximal bulbar urethra to coapt the urethral lumen and increase bladder outlet resistance. A sphincter control pump is placed in the scrotum and connected to a pressure-regulating intraabdominal balloon reservoir by means of subcutaneously placed tubing (Fig 11). Complications related to the AUS include urethral atrophy beneath the cuff, cuff erosion (Fig 12), kinked tubing, pump malfunction, pump migration, and infection (17). Radiologists are often called on to assess the function of these sphincters and evaluate for possible complications.
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Figure 11a. Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.
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Figure 11b. Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.
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Figure 11c. Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.
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Figure 11d. Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.
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Figure 11e. Postprostatectomy urinary incontinence and a normally functioning AUS. (a) Anteroposterior radiograph of the pelvis demonstrates an inflated sphincter cuff (arrow), a connecting tube, a reservoir (R) filled with contrast material, and a radiopaque pump within the scrotum. (b) Voiding cystourethrogram demonstrates the expected appearance of the AUS with the sphincter cuff inflated, which impedes the passage of contrast material (and urine) beyond the cuff. (c) Anteroposterior radiograph of the pelvis shows the scrotal pump being squeezed, which deflates the sphincter cuff to allow micturition. (d) Voiding cystourethrogram demonstrates unimpeded passage of contrast material (arrow) through the deflated cuff. (e) Pelvic CT scan demonstrates the AUS cuff surrounding the urethra. Tubing is seen to the right of the cuff and in the scrotum.
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Figure 12. AUS cuff erosion. Voiding cystourethrogram shows leakage of contrast material around a sphincter cuff (arrows), a finding that indicates cuff erosion through the periurethral soft tissues into the urethral lumen. Contrast material is also seen in the bladder and prostatic fossa.
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Erectile Dysfunction.—
Erectile dysfunction (ED) is the most common complication associated with all of the treatments for prostate cancer and has been reported in 10%–90% of patients after radical prostatectomy. Affected patients are often treated with oral medications such as sildenafil citrate (Viagra; Pfizer, New York, NY) (18). An inflatable penile prosthesis may be offered to patients with ED who are unresponsive to or intolerant of oral medications. Prosthesis placement may be complicated postoperatively by prosthesis erosion into the erectile bodies and soft tissues of the penis.
Tumor Recurrence.—
In patients in whom the PSA level does not become immeasurable after radical surgery, endorectal coil MR imaging is, in our opinion, the optimal imaging modality for demonstrating incompletely resected tumor or residual seminal vesicles or prostatic tissue. Other radiologists and urologists prefer using transrectal US for this purpose. In patients in whom the PSA level becomes detectable again after its postoperative disappearance, these imaging studies may be useful for demonstrating recurrent local disease, thereby directing subsequent therapy to the prostatic bed and often obviating systemic hormonal therapy (Fig 13) (19).
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Figure 13. Residual seminal vesicles after radical retropubic prostatectomy in a patient with an increasing PSA level. T2-weighted MR image obtained with an endorectal coil demonstrates residual seminal vesicles (arrow) as well as metallic clip artifacts.
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Radiation Therapy
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Prostate cancer is responsive to irradiation. Treatment may consist of brachytherapy—administered either alone or in combination with external-beam radiation therapy—external-beam radiation therapy alone, three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, or combinations of androgen suppression therapy and radiation treatment.
Brachytherapy involves imaging (usually transrectal US)–guided implantation of radioactive seeds into the prostate. The goal is to maximize the therapeutic dose to the prostate and decrease the dose to the surrounding tissues.
Conventional two-dimensional external-beam radiation therapy delivers a relatively high radiation dose to the prostate and surrounding tissues. When the delivered dose exceeds 70 Gy, bladder and rectal complications may occur. At doses up to 75 Gy, moderate to severe radiation proctitis occurs in up to 22% of patients; at doses greater than 75 Gy, 60% of patients experience this complication (20). The more recently developed three-dimensional conformal radiation therapy and intensity-modulated radiation therapy allow more precise delivery of a higher radiation dose to the prostate and any extracapsular tumor, with a substantial reduction in dose to the surrounding tissues (20).
Acute effects of radiation therapy in general include transient bladder outlet obstruction, radiation-induced urethritis that manifests as dysuria, severe voiding dysfunction (including increased frequency, urgency, and nocturia) owing to radiation-induced bladder dysfunction, and urethral stricture (Fig 14). In addition, brachytherapy may be associated with edema and hemorrhage resulting from seed implantation.
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Figure 14. Bladder neck contracture in a patient with brachytherapy seeds in the prostate. Simultaneous voiding cystourethrogram (performed through a suprapubic catheter) and retrograde urethrogram demonstrate a short bladder neck contracture (arrow).
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Late complications of both modalities include radiation proctitis, rectal ulceration and rectourinary fistula (Fig 15), sinus tract formation (Fig 16), radiation-induced osteitis (Fig 17), stress urinary incontinence, and ED. Radiation proctitis may occur in up to 10% of patients with seed implantation alone and in 1%–39% who undergo seed implantation combined with external-beam radiation therapy; however, the proctitis is usually mild (21). Stress urinary incontinence is rare after radiation therapy but may occur in up to 12% of patients who have previously undergone transurethral resection of the prostate (22).
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Figure 15. Prostatorectal fistula in a patient who had undergone brachytherapy 1 year earlier and presented after having passed radioactive seeds from the rectum. Voiding cystourethrogram demonstrates a large prostatorectal fistula (arrow), with only four seeds remaining in situ. Left vesicoureteral reflux is also seen. P = prostatic fossa, R = rectum.
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Figure 16a. Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.
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Figure 16b. Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.
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Figure 16c. Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.
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Figure 16d. Radiation-induced prostatosymphyseal sinus tract after transurethral prostatectomy. (a) Sagittal fast spin-echo T2-weighted MR image demonstrates a sinus tract from the prostatic fossa (containing a Foley balloon) to the pubic symphysis. (b) Voiding cystourethrogram also shows the sinus tract (arrow) as well as a contrast material-filled prostatic fossa, the anatomic residua of previously performed transurethral prostatic resection for benign disease. (c) CT scan (soft-tissue window) demonstrates a collection of contrast material and air extending from the pubic symphysis into the anterior abdominal wall. B = enhanced urinary bladder. (d) CT scan (bone window) demonstrates air tracking into the region of the pubic symphysis (arrows). The urinary bladder (B) contains a Foley catheter and is collapsed.
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ED may result from radiation-induced vasculitis. The prevalence of ED is difficult to assess because many patients who undergo brachytherapy or external-beam radiation therapy are older than those treated with surgery and begin treatment with a preexisting history of ED. Potency rates after radiation therapy vary from 34% to 86%. ED rates are somewhat higher in patients treated with external-beam radiation therapy and brachytherapy than in those treated with brachytherapy alone (21).
Radiation seeds may be inadvertently placed into the bladder or rectal wall and may contribute to the urinary, anorectal, and erectile complications of brachytherapy. Complications from malpositioned seeds have not been well described in the literature. The most common inadvertent extraprostatic seed implantation sites are (in order of decreasing frequency) the neurovascular bundles, levator ani muscles, Denonvilliers fascia or rectal wall, genitourinary diaphragm, bladder base, seminal vesicles, corpus spongiosum, and obturator internus muscle (23). Endorectal MR imaging is useful for identifying improper seed placement (Fig 18).
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Figure 18. Misplaced brachytherapy seeds. Axial T1-weighted MR image obtained with an endorectal coil demonstrates brachytherapy seeds within the prostate. Several extraprostatic seeds are present in the perirectal fat (arrows). (Courtesy of Evan S. Siegelman, MD, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia.)
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Cryoablative Therapy
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Cryosurgical ablation is experiencing a resurgence in popularity because of recent technical improvements and the concomitant reduction in treatment-related complications. This technique, which involves transperineal placement of thin cryoprobes into the prostate under transrectal US guidance, offers a potential advantage over conventional surgical treatment in that it allows treatment of locally extensive disease in patients who are not candidates for surgery (24).
In patients who undergo cryoablation of the prostate, necrotic urethral tissue may slough and either pass through the urethra or occlude the urethral lumen. This complication, which was reported in 4%–23% of patients in a recent series (25), results from inadequate urethral warming during the procedure (Fig 19). Urethral stricture may result from extensive tissue sloughing at the bladder neck.
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Figure 19a. Calcified debris after cryoablation of the prostate. (a) Anteroposterior radiograph of the pelvis shows faintly calcified debris (arrows) in the region of the prostatic fossa behind the pubic symphysis. (b) Voiding cystourethrogram shows a large filling defect within the prostatic fossa (arrows), a finding that corresponds to the calcified necrotic debris.
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Figure 19b. Calcified debris after cryoablation of the prostate. (a) Anteroposterior radiograph of the pelvis shows faintly calcified debris (arrows) in the region of the prostatic fossa behind the pubic symphysis. (b) Voiding cystourethrogram shows a large filling defect within the prostatic fossa (arrows), a finding that corresponds to the calcified necrotic debris.
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Like brachytherapy and external-beam radiation therapy, cryotherapy may also be complicated by proctitis, rectal bleeding, and rectal ulceration. Rectourethral fistulas now occur infrequently (0%–3% of cases) (25). Rectourinary fistulas manifest as pneumaturia, fecaluria, or the rectal passage of urine. These fistulas are readily demonstrated at voiding cystourethrography (Fig 20). Cryotherapy is associated with higher rates of ED than are other therapies for localized prostate cancer (24,25).
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Figure 20. Prostatorectal fistula after cryoablation of prostatic carcinoma. Voiding cystourethrogram shows a prostatorectal fistula. The rectum (R) enhanced shortly after the prostatic fossa (P) filled with contrast material. The clips were used for pelvic lymph node dissection.
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Salvage cryotherapy, which is performed for locally recurrent prostate cancer after radiation therapy or hormonal therapy, can cause uncontrollable hematuria, osteitis pubis, bladder outlet obstruction, complete urinary incontinence, ED, and rectourethral fistula (25,26).
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Conclusions
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With improvements in surgical techniques and advances in technology, complications from radical retropubic prostatectomy, radical perineal prostatectomy, brachytherapy, external-beam radiation therapy, and cryosurgical ablation are decreasing but still occur with sufficient frequency to warrant familiarity on the part of radiologists. Knowledge of the possible complications of therapy for carcinoma of the prostate and their radiologic appearances may facilitate their prompt diagnosis and treatment.
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Footnotes
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Abbreviations: AUS = artificial urinary sphincter,
ED = erectile dysfunction,
PSA = prostate-specific antigen,
VUA = vesicourethral anastomosis
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References
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- American Cancer Society Homepage 2004. Available at: www.cancer.org/docroot/home/index.asp. Accessed April 12.
- Scolieri MJ, Resnick MI. The technique of radical perineal prostatectomy. Urol Clin North Am 2001; 28:521-533.[CrossRef][Medline]
- Haab F, Boccon-Bibod L, Delmas LB, Toublanc M. Perineal versus retropubic radical prostatectomy for T1, T2 prostate cancer. BJU 1994; 74:626-629.
- Lepor H. Radical retropubic prostatectomy. Urol Clin North Am 2001; 28:509-519.[CrossRef][Medline]
- Shekarriz B, Upadhyay J, Wood DP. Intraoperative, perioperative, and long-term complications of radical prostatectomy. Urol Clin North Am 2001; 28:639-653.[CrossRef][Medline]
- McLaren RH, Barrett DM, Zincke H. Rectal injury occurring at radical retropubic prostatectomy for prostate cancer: etiology and treatment. Urology 1993; 42:401-405.[CrossRef][Medline]
- Solberg A, Angelsen A, Bergan U, Haugen OA, Viset T, Klepp O. Frequency of lymphoceles after open and laparoscopic pelvic lymph node dissection in patients with prostate cancer. Scand J Urol Nephrol 2003; 37:218-221.[CrossRef][Medline]
- Lepor H. Practical considerations in radical retropubic prostatectomy. Urol Clin North Am 2003; 30:363-368.[CrossRef][Medline]
- Berlin JW, Ramchandani P, Banner MP, Pollack HM, Nodine CF, Wein AJ. Voiding cystourethrography after radical prostatectomy: normal findings and correlation between contrast material extravasation and anastomotic strictures. AJR Am J Roentgenol 1994; 162:87-91.[Abstract/Free Full Text]
- Park R, Martin S, Goldberg JD, Lepor H. Anastomotic strictures following radical prostatectomy: insights into incidence, effectiveness of intervention, effect on continence, and factors predisposing to occurrence. Urology 2001; 57:742-746.[CrossRef][Medline]
- Borboroglu PG, Sands JP, Roberts JL, Amling CL. Risk factors for vesicourethral anastomotic stricture after radical prostatectomy. Urology 2000; 56:96-100.[CrossRef][Medline]
- Levy JB, Ramchandani P, Berlin JW, Broderick GA, Wein AJ. Vesicourethral healing following radical prostatectomy: is it related to surgical approach? Urology 1994; 44:888-892.[CrossRef][Medline]
- Ramchandani P, Banner MP, Berlin JW, Dannenbaum MS, Wein AJ. Vesicourethral anastomotic strictures after radical prostatectomy: efficacy of transurethral balloon dilation. Radiology 1994; 193:345-349.[Abstract/Free Full Text]
- Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996; 156:1707-1713.[CrossRef][Medline]
- Eastham JA, Scardino PT. Radical prostatectomy. In: Campbell MF, Walsh PC, Retik AB, eds. Campbell’s urology. 8th ed. Philadelphia, Pa: Saunders, 2002; 3089-3091.
- Maki DD, Banner MP, Ramchandani P, Stolpen A, Rovner ES, Wein AJ. Injected periurethral collagen for postprostatectomy urinary incontinence: MR and CT appearance. Abdom Imaging 2000; 25:658-662.[CrossRef][Medline]
- Dechet CB, King BF, Barrett DM. Radiology of prostheses for urinary incontinence. In: Pollack HM, McClennan BL, eds. Clinical urography. 2nd ed. Philadelphia, Pa: Saunders, 2000; 2454-2459.
- Zippe CD, Jhaveri FM, Klein EA, et al. Role of Viagra after radical prostatectomy. Urology 2000; 55:241-245.[CrossRef][Medline]
- Manzone TA, Malkowicz SB, Tomaszewski JE, Schnall MD, Langlotz CP. Use of endorectal MR imaging to predict prostate carcinoma recurrence after radical prostatectomy. Radiology 1998; 209:537-542.[Abstract/Free Full Text]
- Thurman SA, Ramakrishna NR, DeWeese TL. Radiation therapy for the treatment of locally advanced and metastatic prostate cancer. Hematol Oncol Clin North Am 2001; 15:423-443.[CrossRef][Medline]
- Stone NN, Stock RG. Practical considerations in permanent brachytherapy for localized adenocarcinoma of the prostate. Urol Clin North Am 2003; 30:351-362.[CrossRef][Medline]
- Ragde H, Blasko JC, Brimm PD, et al. Interstitial iodine-125 radiation without adjuvant therapy in the treatment of clinically localized prostate carcinoma. Cancer 1997; 80:442-453.[CrossRef][Medline]
- Coakley F, Hricak H, Wefer A, Speight JL, Kurhanewicz J, Roach M. Brachytherapy for prostate cancer: endorectal MR imaging of local treatment-related changes. Radiology 2001; 219:817-821.[Abstract/Free Full Text]
- Han KR, Cohen JK, Miller RJ, et al. Treatment of organ confined prostate cancer with third generation cryosurgery: preliminary multicenter experience. J Urol 2003; 170:1126-1130.[CrossRef][Medline]
- Shinohara K. Prostate cancer: cryotherapy. Urol Clin North Am 2003; 30:725-736.[CrossRef][Medline]
- Izawa JI, Ajam K, McGuire E, et al. Major surgery to manage definitively severe complications of salvage cryotherapy for prostate cancer. J Urol 2000; 164:1978-1981.[CrossRef][Medline]
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Abstract
LEARNING OBJECTIVES
