Treatment for Complications of Radiation Therapy in the ... · Treatment for Complications of...
Transcript of Treatment for Complications of Radiation Therapy in the ... · Treatment for Complications of...
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Treatment for Complications of Radiation Therapy in the Cancer
Survivor
Andrew C. Peterson MD, FACSProfessor of Surgery
Duke UniversityDurham, NC
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Disclosures:American Medical Systems: Unrestricted
Educational Grant, Investigator
Coloplast: Unrestricted Educational Grant
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Cancer Epidemiol Biomarkers Prev; 22(4):561, April 2013.
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Surgery
More than you think:-
Wide range in treatment options:-Patient
and Disease factors
Brachytherapy[LDR, HDR]
EBRT[3D-CRT, IMRT, SBRT]
Proton Beam
IORT
Cryotherapy
HIFU
Non-Surgical options
Pelvic Malignancies
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Cancer Epidemiol Biomarkers Prev; 22(4):561, April 2013.
People living with Cancer(N = 14.5M survivors)
(>19 M by 2024)
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Recto-Urethral Fistula;What is Repairable, What is Not?
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Radiation and RUF
6 casesAve time to RUF 22.6 months
4/6 had hyperbaric oxygen treatment prior to development of RUF
2 patients with pelvic exenteration2 successful gracilis interposition
2 remain doubly diverted
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Radiation and RUF: 2004 Brigham and Women Study
7 brachytherapy All diverted
5/7 remain divertedDiverse operations
Ileal loopGracilis
Shah et al Dis Colon Rectum 47:1487-1492, 2004
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RUF Repair Post Radiation• CCF series of 22 patients • 17 definitive repair following double
diversion• 6/17 with preserved fecal and urinary
function
Lane et al J Urology 175:1382-1388, 2006
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CCF RUF Repair Post Radiation Algorithm
Lane et al J Urology 175:1382-1388, 2006
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Suspected Rectourethral Fistula
Appointment with Dr. Peterson @ Dukeor
Appointment with Dr. Lentz @ Duke Raleigh
Patients should have voiding diary, 24‐hr pad weight, AUA symptom score, IIEF‐5 score, ICS male SF questionnaire, RUG, cystoscopy, check nutrition labs, +/‐ smoking referral
Upper tract evaluation
Suprapubic Tube +/‐ nutrition evaluationReferral to Dr. Mantyh, Dr. Migaly, or Dr. Thacker @ Duke
orReferral to Dr. Farkas or Dr. Hopkins @ Duke Raleigh
Wexner symptom score, proctoscopy +/‐anal manometry
Fecal Diversion +/‐nutrition evaluation
Non‐radiated RUF
Suprapubic tube or Foley, Heal x3 months +/‐hyperbaric oxygen treatments
Cystoscopy, RUG/VCUG, proctoscopy +/‐ nutrition labs
<2cm, no stricture, no BNC, distal rectal RUF, good anal fxn
YORK MASON REPAIR
Foley x 3 weeks; SPT x 4 weeks
Pericath RUG/VCUG, proctoscopy
Consider Reversal of Fecal Diversion
If urinary incontinence, consider artificial urinary sphincter at least 6 months after RUF repair
>2cm or in proximal location
Consider perineal repair +/‐ PSU involvement
Post‐Radiation/HIFU/Cryoablation RUF
Heal x4‐6 months +/‐ Hyperbaric oxygen Treatments
Cysto, RUG/VCUG, +/‐ urodynamics, pelvic MRI, proctoscopy, +/‐ nutrition labs
Appointment with Dr. Erdmann or
Duke Raleigh Plastic Surgeon
If Prostatic RUF:(1) Salvage
prostatectomy(2) Omental vsgracilis flap
If <2cm:(1) Primary
Urethra Repair(2) Gracilis Flap
If >2cm or BNC or Membrane Stricture:(1) Buccal Only (2) Gracilis Flap
Foley x 6 weeks, SPT x 8 weeks
PericathRUG/VCUG
Heal x 6 months
Gastrograffin enema, proctoscopyCystoscopy, RUG, urodynamics, voiding diary, pad
weights, quality of life questionnaires
Consider Reversal of Fecal Diversion
If urinary incontinence,
consider artificial urinary sphincter at least 6 months after
RUF repair
If Ablative Tx: (1) Transperineal +/‐transabdominalexcision of cavity
(2) nferior pubectomy(3) Rectal closure
(4) Omental vs gracilisflap
(5) Vesicourethralanastamosis
(6) Wound drainage
If >3cm or fixed tissues, distal fistula, poor rectal tone
Pelvic exenteration with PSU, URO, and CRS
Duke Multidisciplinary Approach to RUF
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Multidisciplinary Approach
• Colo-Rectal Surgery• Plastic Surgery• Nutrition• Wound Care/Stoma nurse
• Clinic appointments scheduled on the same day for patient convenience
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Suspected RUFFistula
Appointment with Duke Urology
Patients should have voiding diary, 24-hr pad weight, AUA symptom score, IIEF-5 score, ICS male SF questionnaire, RUG,
cystoscopy, check nutrition labs, +/- smoking referralUpper tract evaluation
Suprapubic Tube +/- nutrition evaluation Referral to Duke Colorectal Surgery
Wexner symptom score, proctoscopy +/- anal manometry
Fecal Diversion +/- nutritional evaluation
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Non-radiated RUF
Suprapubic tube/Foley, fecal diversion Heal x3 months +/- hyperbaric oxygen treatments
Cystoscopy, RUG/VCUG, proctoscopy +/- nutrition labs
<2cm, no stricture, no BNC, distal rectal RUF, good anal fxn
>2cm or in proximal location
Consider perineal repair +/-PSU involvement
York Mason Repair
Foley x 3 weeks; SPT x 4 weeks
Pericath RUG/VCUG, proctoscopy
Consider Reversal of Fecal Diversion , GGE
If urinary incontinence, consider artificial urinary sphincter at least 6 months after
RUF repair
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If Prostatic RUF:(1) Salvage
prostatectomy(2) Omental vs
gracilis flap
If <2cm:(1) Primary
Urethra Repair(2) Gracilis
Flap
If >2cm or BNC or Membrane
Stricture:(1) Buccal Only (2) Gracilis Flap
If Ablative Tx: (1) Transperineal +/-
transabdominal excision of cavity
(2) inferior pubectomy(3) Rectal closure
(4) Omental vs gracilis flap(5) Vesicourethral
anastamosis(6) Wound drainage
Foley x 6 weeks, SPT x 8 weeks
Pericath RUG/VCUG
Heal x 6 months
Gastrograffin enema, proctoscopyCystoscopy, RUG, urodynamics, voiding diary,
pad weights, quality of life questionnaires
Consider Reversal of Fecal DiversionIf urinary incontinence, consider artificial urinary sphincter at least 6
months after RUF repair
Radiated RUF
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If >3cm or fixed tissues, distal fistula, poor rectal tone
Pelvic exenteration with PSU, URO, and CRS
Radiated RUF
These are fortunately rare, but heroic efforts to fix a huge radiated RUF will usually disappoint
the patient and surgeon
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Thank You• Duke Urology
– Erin McNamara, Ray Bernal• Duke Plastic Surgery
– Detlev Erdmann, Howard Levinson • Duke Colorectal Surgery
– Chris Mantyh, John Migaly, Julie Thacker, Ben Hopkins, Linda Farkas, Jennifer Hanna, Ryan Turley
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Osteomyelitis of the Pubic Symphisis
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We recognized a strange syndrome
Long term survivors presenting with:
Introduction
Chronic pelvic pain – “prostatitis”Recurrent UTI
Recurrent skin infectionsRecurrent AUS/IPP Infections
Strange thigh and abdominal wall abscess
Pain with walking
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Our Patient78 year old male with prior Gleason 6 CaPTreated with Brachytherapy 7 years ago
Developed strictureTUR
Pain + StrictureRedo-TUR
Problems walkingChronic UTI
Pain
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Clearly demonstrated bone infection
Recognized the etiology
Through serendipity:
MRI for possible spine etiology of pain
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Our Series
23 between 2011 and 2016Mean age 70Patients
Cancer Treatment #EBRT 6
RP + EBRT 8
Brachy + EBRT 6
EBRT + salvage cryo 2
HIFU 1
Precipitating procedure in 18 out of 23cases
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Presentation
AverageTime fromtreatment
8 years
# %Pelvic pain 22 96%Perineum, groin, thigh abscess/sinus
13 57%
Recurrent UTIs 15 65%Sepsis 5 22%Cellulitis 5 22%
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Imaging !All: Increased T2-weighted sequences
Decreased signal on T1-weighted sequences
69%: High T2 signal at the origin of the obturator and adductor muscle groups
63%: Diastasis of the pubic symphysis with cortical bone erosion
75%: Fluid collection associated with the periprostatic space, parasymphseal region and rectus muscle
65%: Plain films demonstrated no radiographic evidence of pubic symphysis osteomyelitis
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Imaging !
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Imaging !
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Imaging !
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Imaging !
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Imaging !
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The Duke Algorithm
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Surgery !
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Surgery !
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Surgery !
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Osteomyelitis
23
Results
Stable without surgery
2Surgery
21
2011 - 2016
+ Cystectomy
20- Cystectomy
1
Redo Debridement
2Resolved
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Outcomes
Mean length of stay: 10 days (range 6-24)Post-op ileus
HerniaFluid collection
Results
Immediate resolution of pain in all !
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Take Home Point : -
“Pelvic pain and/or I keep getting infections”
What to look for ?
Osteomyelitis
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Thank You• Duke Urology
– Shubham Gupta Jim Belsante Patrick Selph– Uwais Zaid Garjae Lavien
• Duke Orthopedic ID– Ted Hendershot
• Duke Orthopedics– Bob Zura– Will Eward
• Duke Plastic Surgery– Detlev Erdmann
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EVALUATION AND MANAGEMENT OF URINARY INCONTINENCE IN FEMALE
PATIENTS AFTER RADIATION:Complex Vesico-vaginal Fistula
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33 y/o AA Female with history of cervical cancer
Referred for possible reconstructive options.
HOWEVER…
CC: “I was sent here to fix the urine from my vagina”
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Finished radiation 10 months ago! Living with incontinence Had flank pain. Imaging: hydronephrosis on
right. Had PCN placed
CC: “And…to get rid of this tube!”
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Urinary Diversion:More Options, Better Outcomes
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Proper Patient Selection
Goals of urinary diversion:Safest procedure for the patient
Minimize complications
Maximize quality of life
Continent diversion not always the best choice
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Quality of LifeMost reports compare continent to loop diversion
Little to no difference foundFew reports comparing different continent diversions
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Source of Diversion
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(1975). "Transverse colon conduit: a preferred method of urinary diversion for radiation-treated
pelvic malignancies.". The Journal of urology(0022-5347), 113(3), p.308.
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Ileal ConduitNo CICIncontinent diversion
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Continent Urinary Diversion
Must be able to CICRight Colon Pouch
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The Bladder“To take…or not to take?”
YES
Minimal morbidity30 Minutes
<300 cc EBLPyocystis
Risk of cancerBleeding
Pain
No
Less morbidityLess time
Less blood lossNot needed
Wound closure issues
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Extirpative Surgery:Sometimes necessary
Beware progressive disease with radiation
Select for continent and non-continent diversion options
Can use small bowel – cautiously
Consider removal of the native bladder
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Conclusion
• Radiation survivors are common
• May be tough to care for
• Solutions exist
• Beware the lower tract in the radiated survivor
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“The best interest of the patient is the
only interest to be
considered.”
William J. Mayo, M.D.1861-1939