Factors predicting for urinary incontinence after prostate brachytherapy

Abstract

Purpose To define risk factors that predict for urinary incontinence after 125I prostate brachytherapy. Methods and materials Urinary incontinence after 125I prostate brachytherapy was evaluated using a patient self-assessment questionnaire based on the NCI Common Toxicity Criteria (version 2). Grade 0 is defined as no incontinence; Grade 1 incontinence occurs with coughing, sneezing, or laughing; Grade 2 is spontaneous incontinence with some control; and Grade 3 is no control. One hundred fifty-three patients received monotherapy (145 Gy) 125I implants between October 1996 and December 2001, and 112 (75%) responded to our survey. Median follow-up was 47 months (range, 14–74 months). Patient characteristics included a preimplant prostate-specific antigen ≤10, Gleason score ≤6, and stage ≤T2b. CT-based postimplant dosimetry was analyzed approximately 30 days after the procedure, and dose–volume histograms of the prostate and the prostatic urethra were generated based on contoured volumes. Dosimetric parameters evaluated as predictive factors for incontinence included the prostate volume; total activity implanted; number of needles; number of seeds; seed activity; urethral D 5, D 10, D 25, D 50, D 75, and D 90 doses; prostate D 90 doses; and prostate V 100, V 200, and V 300. Clinical parameters evaluated included age, Gleason score, prostate-specific antigen, preimplant International Prostate Symptom Score (I-PSS), and length of follow-up. Results Urethral D 10 dose and preimplant I-PSS predicted for urinary incontinence on multivariate analysis ( p = 0.002 and p = 0.003, respectively). Twenty-eight patients reported Grade 1 incontinence (26%), and 5 patients reported Grade 2 (5%). Patients with Grade 1 and 2 incontinence were analyzed together, because of the small number of patients who experienced Grade 2. No patients reported Grade 3 incontinence. Mean urethral D 10 was 314 ± 78 Gy in patients with Grade 0 compared with 394 ± 147 Gy in patients with Grades 1, 2 incontinence ( p = 0.002). The incidence of incontinence doubled as the urethral D 10 dose increased above 450 Gy. Patients with Grade 0 had a mean preimplant I-PSS score of 6.6 ± 4.5 compared with 10.0 ± 6.4 for Grades 1, 2 ( p = 0.003). A significant increase in the incidence of incontinence was noted when the preimplant I-PSS was greater than 15. No relationship was noted between incontinence and prostate volume, total activity implanted, or the number of needles used ( p = 0.83, p = 0.89, p = 0.36, respectively). Conclusion Urethral D 10 dose and preimplant I-PSS are predictive for patients at higher risk of urinary incontinence. To decrease the risk of this complication, an effort should be made to keep the urethral D 10 dose as close to the prescribed dose as possible, and the preimplant I-PSS should be thoroughly evaluated in an attempt to select patients with scores less than 15.