The Potential Impact of Adjuvant Radiation Therapy on Urinary Continence Recovery After Radical Prostatectomy

Abstract

Recent publications from the Department of Urology at Vita-Salute University were devoted to the positive impact of adjuvant radiotherapy (aRT) after pelvic lymphadenectomy and radical prostatectomy (RP) for prostate cancer [1,2]. A new publication shed light on the potential detrimental effect of aRT on urinary continence (UC) in a series of 361 contemporary patients classified with pT2 R1 or pT3a/pT3b node-negative disease with unfavourable pathologic characteristics [3]. Such a statement may make urologists and patients ambivalent towards the value of aRT and justifies a critical analysis. Urologists do not want to face complaints from patients after aRT, particularly if the indication for aRT was questionable, and patients want to enjoy not only a cancer-free status but also a life free of physical and psychological health problems related to cancer and/or its treatment. In the Milan series [1,2], aRT was not assigned randomly, making the interaction of treatment exposure and patient characteristics likely, and the two cohorts harboured significant differences unfavourable to aRT with regard to age, pathologic stage, Gleason score, Cancer of the Prostate Risk Assessment (CAPRA) score used as a proxy for disease severity, and bilateral nerve-sparing approach. Other parameters were missing but also could be unfavourable to aRT: (1) the breakdown of the surgical margin positivity for pT3a-b stage; (2) the percentage of patients not achieving undetectable prostate-specific antigen (PSA); and (3) UC status at the delivery of aRT, of paramount importance because incontinence contraindicates aRT unless the patient has grade 1 urinary incontinence (coughing, sneezing). With a mean follow-up of 30 mo, the Milan series did not display late toxicity analysis but rather 3-yr UC recovery of 59% for patients submitted to aRT