Clin Colon Rectal Surg 2022; 35(03): 204-211
DOI: 10.1055/s-0041-1740041
Review Article

Pelvic Radiation Disease

Tarik Sammour
1   Department of Colorectal Surgery, University of Adelaide, Royal Adelaide Hospital, Wayfinding, Adelaide, Australia
Arman A. Kahokehr
2   Department of Urology, Flinders University, Lyell McEwin Hospital, Adelaide, Australia
› Author Affiliations


Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.

Publication History

Article published online:
12 February 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Bach SP, Gilbert A, Brock K. et al; TREC collaborators. Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study. Lancet Gastroenterol Hepatol 2021; 6 (02) 92-105
  • 2 Podder TK, Fredman ET, Ellis RJ. Advances in radiotherapy for prostate cancer treatment. Adv Exp Med Biol 2018; 1096: 31-47
  • 3 Patel NV, Yu NY, Koroulakis A. et al. Proton therapy for thoracic malignancies: a review of oncologic outcomes. Expert Rev Anticancer Ther 2021; 21 (02) 177-191
  • 4 Handmer M, Martin J, Tiu A. Costing urologic complications following pelvic radiation therapy. Urology 2020; 140: 64-69
  • 5 Matta R, Chapple CR, Fisch M. et al. Pelvic complications after prostate cancer radiation therapy and their management: an international collaborative narrative review. Eur Urol 2019; 75 (03) 464-476
  • 6 Do NL, Nagle D, Poylin VY. Radiation proctitis: current strategies in management. Gastroenterol Res Pract 2011; 2011: 917941
  • 7 Hayne D, Vaizey CJ, Boulos PB. Anorectal injury following pelvic radiotherapy. Br J Surg 2001; 88 (08) 1037-1048
  • 8 Takeuchi H, Kimura T, Okamoto K. et al. A mechanism for abnormal angiogenesis in human radiation proctitis: analysis of expression profile for angiogenic factors. J Gastroenterol 2012; 47 (01) 56-64
  • 9 Weiner J, Schwartz D, Martinez M, Safdieh J, Aytaman A, Schreiber D. Long-term results on the efficacy of argon plasma coagulation for patients with chronic radiation proctitis after conventionally fractionated, dose-escalated radiation therapy for prostate cancer. Pract Radiat Oncol 2017; 7 (01) e35-e42
  • 10 Weiner JP, Wong AT, Schwartz D, Martinez M, Aytaman A, Schreiber D. Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding. World J Gastroenterol 2016; 22 (31) 6972-6986
  • 11 Gentile M, Cestaro G, Formisano C, Sivero L. Treatment and outcomes of patients with chronic radiation proctitis. A single-center experience and review of the literature. Ann Ital Chir 2020; 91: 668-672
  • 12 Denton AS, Andreyev HJ, Forbes A, Maher EJ. Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer 2002; 87 (02) 134-143
  • 13 Nelamangala Ramakrishnaiah VP, Krishnamachari S. Chronic haemorrhagic radiation proctitis: a review. World J Gastrointest Surg 2016; 8 (07) 483-491
  • 14 Yuan JH, Song LM, Liu Y. et al. The effects of hyperbaric oxygen therapy on pelvic radiation induced gastrointestinal complications (rectal bleeding, diarrhea, and pain): a meta-analysis. Front Oncol 2020; 10: 390
  • 15 Browne C, Davis NF, Mac Craith E. et al. A narrative review on the pathophysiology and management for radiation cystitis. Adv Urol 2015; 2015: 346812
  • 16 Pascoe C, Duncan C, Lamb BW. et al. Current management of radiation cystitis: a review and practical guide to clinical management. BJU Int 2019; 123 (04) 585-594
  • 17 Giannitsas K, Athanasopoulos A. Intravesical therapies for radiation cystitis. Curr Urol 2015; 8 (04) 169-174
  • 18 Villeirs L, Tailly T, Ost P. et al. Hyperbaric oxygen therapy for radiation cystitis after pelvic radiotherapy: systematic review of the recent literature. Int J Urol 2020; 27 (02) 98-107
  • 19 Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for refractory hemorrhagic cystitis: contemporary etiology, presentation and outcomes. J Urol 2014; 192 (06) 1687-1692
  • 20 Hechenbleikner EM, Buckley JC, Wick EC. Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes. Dis Colon Rectum 2013; 56 (03) 374-383
  • 21 Hanna JM, Peterson AC, Mantyh C. Rectourethral fistulas in the cancer survivor. Curr Opin Urol 2014; 24 (04) 382-388
  • 22 Hanna JM, Turley R, Castleberry A. et al. Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients. Dis Colon Rectum 2014; 57 (09) 1105-1112
  • 23 Mishra K, Mahran A, Abboud B. et al. Validating the Martini staging system for rectourethral fistula: a meta-analysis of postoperative outcomes. Urology 2021; 147: 299-305
  • 24 Martini A, Gandaglia G, Nicita G, Montorsi F. A novel classification proposal for rectourethral fistulas after primary treatment of prostate cancer. Eur Urol Oncol 2018; 1 (06) 510-511
  • 25 Harris CR, McAninch JW, Mundy AR. et al. Rectourethral fistulas secondary to prostate cancer treatment: management and outcomes from a multi-institutional combined experience. J Urol 2017; 197 (01) 191-194
  • 26 Monn MF, Roth JD, Bihrle R, Mellon MJ. Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures. Int Urol Nephrol 2018; 50 (08) 1375-1380
  • 27 Goitz RJ, Tomaino MM, Smith P, Hannallah D, Sinha R. Treatment of radiation-induced soft-tissue fibrosis and concomitant acetabular osteonecrosis: a case report. Am J Orthop 2007; 36 (04) E56-E58
  • 28 Kang HS, Kim T, Chung SH. Resection arthroplasty in radiation-induced osteonecrosis of the hip. J Clin Orthop Trauma 2019; 10 (02) 364-367
  • 29 Quinlan JF, North J, Clarke DA, Gwynne-Jones DP. Radiation-induced osteonecrosis of the hips following genital-preserving surgery and chemoradiotherapy. N Z Med J 2009; 122 (1297): 84-86
  • 30 Wignall TA, Carrington BM, Logue JP. Post-radiotherapy osteomyelitis of the symphysis pubis: computed tomographic features. Clin Radiol 1998; 53 (02) 126-130
  • 31 Matsushita K, Ginsburg L, Mian BM. et al. Pubovesical fistula: a rare complication after treatment of prostate cancer. Urology 2012; 80 (02) 446-451
  • 32 Kahokehr AA, Boysen WR, Schild MH. et al. Urinary pubic symphysis fistula leads to histopathologic osteomyelitis in prostate cancer survivors. Urology 2021; 148: 297-301
  • 33 Bugeja S, Andrich DE, Mundy AR. Fistulation into the pubic symphysis after treatment of prostate cancer: an important and surgically correctable complication. J Urol 2016; 195 (02) 391-398
  • 34 Gupta S, Zura RD, Hendershot EF, Peterson AC. Pubic symphysis osteomyelitis in the prostate cancer survivor: clinical presentation, evaluation, and management. Urology 2015; 85 (03) 684-690
  • 35 Lavien G, Chery G, Zaid UB, Peterson AC. Pubic bone resection provides objective pain control in the prostate cancer survivor with pubic bone osteomyelitis with an associated urinary tract to pubic symphysis fistula. Urology 2017; 100: 234-239
  • 36 Wallington DG, Holliday EB. Preparing patients for sexual dysfunction after radiation for anorectal cancers: a systematic review. Pract Radiat Oncol 2021; 11 (03) 193-201
  • 37 Moroney MR, Flink D, Sheeder J. et al. Radiation therapy is not an independent risk factor for decreased sexual function in women with gynecologic cancers. Rep Pract Oncol Radiother 2018; 23 (05) 331-336
  • 38 Nguyen DD, Berlin A, Matthew AG, Perlis N, Elterman DS. Sexual function and rehabilitation after radiation therapy for prostate cancer: a review. Int J Impot Res 2021; 33 (04) 410-417
  • 39 Yerramilli D, Drapek L, Nipp RD. et al. Sexual function, quality of life, and mood after radiation therapy in patients with anal cancer. J Gastrointest Cancer 2020; 51 (01) 204-210
  • 40 Hamstra DA, Mariados N, Sylvester J. et al. Sexual quality of life following prostate intensity modulated radiation therapy (IMRT) with a rectal/prostate spacer: Secondary analysis of a phase 3 trial. Pract Radiat Oncol 2018; 8 (01) e7-e15
  • 41 Laviana AA, Zhao Z, Huang LC. et al. Development and internal validation of a web-based tool to predict sexual, urinary, and bowel function longitudinally after radiation therapy, surgery, or observation. Eur Urol 2020; 78 (02) 248-255
  • 42 Chapman CH, Heath G, Fairchild P. et al. Gynecologic radiation oncology patients report unmet needs regarding sexual health communication with providers. J Cancer Res Clin Oncol 2019; 145 (02) 495-502
  • 43 Wo JY, Drapek LC, Niemierko A. et al. Clinical needs assessment for sexual health among cancer patients receiving pelvic radiation: Implications for development of a radiation oncology sexual health clinic. Pract Radiat Oncol 2018; 8 (03) 206-212
  • 44 Araya-Castro P, Sacomori C, Diaz-Guerrero P, Gayán P, Román D, Sperandio FF. Vaginal dilator and pelvic floor exercises for vaginal stenosis, sexual health and quality of life among cervical cancer patients treated with radiation: clinical report. J Sex Marital Ther 2020; 46 (06) 513-527
  • 45 Bakker RM, ter Kuile MM, Vermeer WM. et al. Sexual rehabilitation after pelvic radiotherapy and vaginal dilator use: consensus using the Delphi method. Int J Gynecol Cancer 2014; 24 (08) 1499-1506
  • 46 Dess RT, Devasia TP, Aghdam N. et al. Patient-reported sexual aid utilization and efficacy after radiation therapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 2018; 101 (02) 376-386