Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
414
M. DeLeon and L. Stocchi
many women may not be forthcoming with their
concerns. Use of the Female Sexual Function
Index-9 (FSFI-9) Questionnaire and the Pelvic
Organ Prolapse/Incontinence Sexual International
Urogynecological Association-Revised
Questionnaire are useful tools for guiding diagnosis and management.
Treatment
A multidisciplinary approach between colorectal
surgery, urogynecology and women’s health is
essential for optimal therapy. For patients suffering from sexual dysfunction, therapies including
vaginal lubrication, topical and hormonal
replacement therapy, pelvic oor physical therapy and psychological counseling are used
depending on symptomatology. Patients with urinary incontinence, should have a referral to urology or urogynecology for medical management,
pelvic oor physical therapy, and consideration
of sacral nerve stimulation.
References
1. Alsanea N, Alabbad S. Use of the endostapler for
the treatment of non-healing sinus secondary to a
dehisced colorectal anastomosis. Tech Coloproctol.
2010;14:249–51. https://doi.org/10.1007/
s10151- 010- 0600- 5.
2. Annicchiarico A, Martellucci J, Solari S, etal. Low
anterior resection syndrome: can it be prevented? Int J
Color Dis. 2021;36:2535–52. https://doi.org/10.1007/
s00384- 021- 04008- 3.
3. Ballard DH, Gates MC, Hamidian Jahromi A, etal.
Transrectal and transvaginal catheter drainages and
aspirations for management of pelvic uid collections:
technique, technical success rates, and outcomes in
150 patients. Abdom Radiol (NY). 2019;44:2582–93.
https://doi.org/10.1007/s00261- 019- 01974- 9.
4. Blumetti J, Chaudhry V, Prasad L, Abcarian
H. Delayed transanal repair of persistent coloanal
anastomotic leak in diverted patients after resection
for rectal cancer. Color Dis. 2012;14:1238–41. https://
doi.org/10.1111/j.1463- 1318.2012.02932.x.
5. Borstlap WAA, Musters GD, LPS S, et al. Vacuumassisted early transanal closure of leaking low
colorectal anastomoses: the CLEAN study. Surg
Endosc. 2018;32:315–27. https://doi.org/10.1007/
s00464- 017- 5679- 6.
6. Borstlap WAA, Westerduin E, Aukema TS, et al.
Anastomotic leakage and chronic presacral sinus for-
mation after low anterior resection: results from a large
cross-sectional study. Ann Surg. 2017;266:870–7.
https://doi.org/10.1097/SLA.0000000000002429.
7. Braley SC, Schneider PD, Bold RJ, etal. Controlled
tamponade of severe presacral venous hemorrhage: use of a breast implant sizer. Dis Colon
Rectum. 2002;45:140–2. https://doi.org/10.1007/
s10350- 004- 6130- 3.
8. Braunschmid T, Hartig N, Baumann L, et al.
Inuence of multiple stapler rings used for rectal
division on colorectal anastomotic leak rate. Surg
Endosc. 2017;31:5318–26. https://doi.org/10.1007/
s00464- 017- 5611- 0.
9. Brehant O, Hanes A, Fuks D, etal. Stapled marsupialisation of chronic low rectal anastomotic sinuses. Int
J Color Dis. 2009;24:1233–7. https://doi.org/10.1007/
s00384- 009- 0780- 5.
10. Brown CJ, Fenech D, McLeod RS.Reconstructive
techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev.
2008, 2008;(2):CD006040. https://doi.
org/10.1002/14651858.CD006040.pub2.
11. Butch RJ, Mueller PR, Ferrucci JT, etal. Drainage
of pelvic abscesses through the greater sciatic foramen. Radiology. 1986;158:487–91. https://doi.
org/10.1148/radiology.158.2.3941878.
12. Cabellos Olivares M, Labalde Martínez M, Torralba
M, etal. C-reactive protein as a marker of the surgical
stress reduction within an ERAS protocol (Enhanced
recovery after surgery) in colorectal surgery: a prospective cohort study. J Surg Oncol. 2018;117:717–24.
https://doi.org/10.1002/jso.24909.
13. Calmels M, Collard MK, O’Connell L, etal. Redosurgery after failed colorectal or coloanal anastomosis: morbidity, mortality and factors predictive
of success. A retrospective study of 200 patients.
Color Dis. 2022;24:511–9. https://doi.org/10.1111/
codi.16025.
14. Casal Núñez JE, Vigorita V, Ruano Poblador A, etal.
Presacral venous bleeding during mobilization in rectal cancer. World J Gastroenterol. 2017;23:1712–9.
https://doi.org/10.3748/wjg.v23.i9.1712.
15. Chorti A, Stavrou G, Stelmach V, et al. Endoscopic
repair of anastomotic leakage after low anterior resection for rectal cancer: a systematic review. Asian J
Endosc Surg. 2020;13:141–6. https://doi.org/10.1111/
ases.12733.
16. De Nardi P, Elmore U, Maggi G, et al.
Intraoperative angiography with indocyanine green
to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results
of a multicenter randomized controlled trial. Surg
Endosc. 2020;34:53–60. https://doi.org/10.1007/
s00464- 019- 06730- 0.
17. Dhindsa BS, Naga Y, Saghir SM, et al. Endosponge in management of anastomotic colorectal leaks: a systematic review and meta- analysis.
Endosc Int Open. 2021;9:E1342–9. https://doi.
org/10.1055/a- 1490- 8783.
18. Emile SH, Garoufalia Z, Barsom S, etal. Systematic
review and meta-analysis of randomized clinical trials
36 Rectal andRectosigmoid Carcinoma
415
on the treatment of low anterior resection syndrome.
Surgery. 2023;173:1352–8. https://doi.org/10.1016/j.
surg.2023.02.010.
19. Emmertsen KJ, Laurberg S. Low anterior resection
syndrome score: development and validation of a
symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.
Ann Surg. 2012;255:922–8. https://doi.org/10.1097/
SLA.0b013e31824f1c21.
20. Garcia-Granero A, Sánchez-Guillén L, Carreño O,
etal. Importance of the Moskowitz artery in the laparoscopic medial approach to splenic exure mobilization:
a cadaveric study. Tech Coloproctol. 2017;21:567–72.
https://doi.org/10.1007/s10151- 017- 1663- 3.
21. Gee MS, Kim JY, Gervais DA, etal. Management of
abdominal and pelvic abscesses that persist despite
satisfactory percutaneous drainage catheter placement. AJR Am J Roentgenol. 2010;194:815–20.
https://doi.org/10.2214/AJR.09.3282.
22. Ha GW, Kim JH, Lee MR.Oncologic impact of anastomotic leakage following colorectal cancer surgery:
a systematic review and meta-analysis. Ann Surg
Oncol. 2017;24:3289–99. https://doi.org/10.1245/
s10434- 017- 5881- 8.
23. Harisinghani MG, Gervais DA, Maher MM, et al.
Transgluteal approach for percutaneous drainage
of deep pelvic abscesses: 154 cases. Radiology.
2003;228:701–5. https://doi.org/10.1148/
radiol.2283020924.
24. Harrison JL, Hooks VH, Pearl RK, et al. Muscle
fragment welding for control of massive presacral
bleeding during rectal mobilization: a review of eight
cases. Dis Colon Rectum. 2003;46:1115–7. https://
doi.org/10.1007/s10350- 004- 7289- 3.
25. He S, Zhang J, Wang R, etal. Impact of long-course
neoadjuvant radiation on postoperative low anterior
resection syndrome and stoma status in rectal cancer: long-term functional follow-up of a randomized
clinical trial. BJS Open. 2022;6:zrac127. https://doi.
org/10.1093/bjsopen/zrac127.
26. Huang Y, Koh CE. Sacral nerve stimulation for
bowel dysfunction following low anterior resection:
a systematic review and meta-analysis. Color Dis.
2019;21:1240–8. https://doi.org/10.1111/codi.14690.
27. Hüttner FJ, Tenckhoff S, Jensen K, etal. Meta-analysis
of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg. 2015;102:735–45.
https://doi.org/10.1002/bjs.9782.
28. Jafari MD, Pigazzi A, McLemore EC, etal. Perfusion
Assessment in Left-Sided/Low Anterior Resection
(PILLAR III): a randomized, controlled, parallel, multicenter study assessing perfusion outcomes
with PINPOINT near-infrared uorescence imaging in low anterior resection. Dis Colon Rectum.
2021;64:995–1002. https://doi.org/10.1097/
DCR.0000000000002007.
29. Jain D, Sandhu N, Singhal S.Endoscopic electrocautery incision therapy for benign lower gastrointestinal tract anastomotic strictures. Ann Gastroenterol.
2017;30:473–85. https://doi.org/10.20524/
aog.2017.0163.
30. Jutesten H, Buchwald PL, Angenete E, et al.
High risk of low anterior resection syndrome in
long-term follow-up after anastomotic leakage
in anterior resection for rectal cancer. Dis Colon
Rectum. 2022;65:1264–73. https://doi.org/10.1097/
DCR.0000000000002334.
31. Kamal T, Pai A, Velchuru VR, etal. Should anastomotic assessment with exible sigmoidoscopy be routine following laparoscopic restorative left colorectal
resection? Color Dis. 2015;17:160–4. https://doi.
org/10.1111/codi.12809.
32. Karatay E, Javadov M. The importance of the
Moskowitz artery as a lesser-known collateral pathway in the medial laparoscopic approach to splenic
exure mobilisation and its evaluation with preoperative computed tomography. Wideochir Inne
Tech Maloinwazyjne. 2021;16:305–11. https://doi.
org/10.5114/wiitm.2020.100826.
33. Keane C, Sharma P, Yuan L, et al. Impact of temporary ileostomy on long-term quality of life and bowel
function: a systematic review and meta-analysis. ANZ
J Surg. 2020;90:687–92. https://doi.org/10.1111/
ans.15552.
34. Kirat HT, Remzi FH, Shen B, Kiran RP. Pelvic
abscess associated with anastomotic leak in patients
with ileal pouch-anal anastomosis (IPAA): transanastomotic or CT-guided drainage? Int J Color
Dis. 2011;26:1469–74. https://doi.org/10.1007/
s00384- 011- 1272- y.
35. Lamazza A, Fiori E, Sterpetti AV, et al. Selfexpandable metal stents in the treatment of benign
anastomotic stricture after rectal resection for cancer.
Color Dis. 2014;16:O150–3. https://doi.org/10.1111/
codi.12488.
36. Lavryk OA, Bandi B, Shawki SF, et al. TurnbullCutait abdominoperineal pull-through operation:
the Cleveland Clinic experience in the 21st century.
Color Dis. 2022;24:1184–91. https://doi.org/10.1111/
codi.16163.
37. Malik AH, East JE, Buchanan GN, Kennedy
RH. Endoscopic haemostasis of staple-line
haemorrhage following colorectal resection.
Color Dis. 2008;10:616–8. https://doi.
org/10.1111/j.1463- 1318.2007.01459.x.
38. Meyer J, Naiken S, Christou N, et al. Reducing
anastomotic leak in colorectal surgery: the old dogmas and the new challenges. World J Gastroenterol.
2019;25:5017–25. https://doi.org/10.3748/wjg.v25.
i34.5017.
39. Moszkowicz D, Alsaid B, Bessede T, et al. Where
does pelvic nerve injury occur during rectal surgery
for cancer? Color Dis. 2011;13:1326–34. https://doi.
org/10.1111/j.1463- 1318.2010.02384.x.
40. Ng X, Chiou W, Chang S. Controlling a presacral
hemorrhage by using a saline bag: report of a case.
Dis Colon Rectum. 2008;51:972–4. https://doi.
org/10.1007/s10350- 007- 9189- 9.
416
M. DeLeon and L. Stocchi
41. Phitayakorn R, Delaney CP, Reynolds HL, et al.
Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J
Surg. 2008;32:1147–56. https://doi.org/10.1007/
s00268- 008- 9468- 1.
42. Picazo-Ferrera K, Jaurrieta-Rico C, Manzano-Robleda
M, et al. Risk factors and endoscopic treatment for
anastomotic stricture after resection in patients with
colorectal cancer. Rev Gastroenterol Mex (Engl
Ed). 2021;86:44–50. https://doi.org/10.1016/j.
rgmx.2020.03.001.
43. Rahbari NN, Weitz J, Hohenberger W, et al.
Denition and grading of anastomotic leakage following anterior resection of the rectum: a proposal
by the International Study Group of Rectal Cancer.
Surgery. 2010;147:339–51. https://doi.org/10.1016/j.
surg.2009.10.012.
44. Remzi FH, Oncel M, Fazio VW. Muscle tamponade
to control presacral venous bleeding: report of two
cases. Dis Colon Rectum. 2002;45:1109–11. https://
doi.org/10.1007/s10350- 004- 6369- 8.
45. Ricciardi R, Roberts PL, Marcello PW, et al.
Anastomotic leak testing after colorectal resection:
what are the data? Arch Surg. 2009;144:407–11;
discussion 411–412. https://doi.org/10.1001/
archsurg.2009.43.
46. Rondelli F, Pasculli A, De Rosa M, etal. Is routine
splenic exure mobilization always necessary in
laparotomic or laparoscopic anterior rectal resection? A systematic review and comprehensive metaanalysis. Updat Surg. 2021;73:1643–61. https://doi.
org/10.1007/s13304- 021- 01135- y.
47. Rosen HR, Kneist W, Fürst A, et al. Randomized
clinical trial of prophylactic transanal irrigation versus supportive therapy to prevent symptoms of low
anterior resection syndrome after rectal resection.
BJS Open. 2019;3:461–5. https://doi.org/10.1002/
bjs5.50160.
48. Singh A, Kishore R, Saxena SS.Ligating internal iliac
artery: success beyond hesitation. J Obstet Gynaecol
India. 2016;66:235–41. https://doi.org/10.1007/
s13224- 016- 0859- 1.
49. Sirois-Giguère E, Boulanger-Gobeil C, Bouchard A,
et al. Transanal drainage to treat anastomotic leaks
after low anterior resection for rectal cancer: a valuable option. Dis Colon Rectum. 2013;56:586–92.
https://doi.org/10.1097/DCR.0b013e31827687a4.
50. Sturiale A, Martellucci J, Zurli L, etal. Long-term
functional follow-up after anterior rectal resection
for cancer. Int J Color Dis. 2017;32:83–8. https://doi.
org/10.1007/s00384- 016- 2659- 6.
51. Sun R, Dai Z, Zhang Y, et al. The incidence and risk
factors of low anterior resection syndrome (LARS)
after sphincter-preserving surgery of rectal cancer: a
systematic review and meta-analysis. Support Care
Cancer. 2021;29:7249–58. https://doi.org/10.1007/
s00520- 021- 06326- 2.
52. Toh JWT, Matthews R, Kim S-H. Arc of Riolanpreserving splenic exure takedown during anterior
resection: potentially critical to prevent acute anastomotic ischemia. Dis Colon Rectum. 2018;61:411–4.
https://doi.org/10.1097/DCR.0000000000000995.
53. van Doesburg IAJ, Boerma D, Bollen TL,
et al. Large gluteal abscesses as a complication of transgluteal drainage of pelvic abscesses:
analysis of three cases and a search of the literature. Dig Surg. 2009;26:329–32. https://doi.
org/10.1159/000235821.
54. Vargas HD, Margolin DA . Anastomotic construction.
ASCRS textbook of colon and rectal surgery, 2022.
ASCRS U, www.ascrsu.com/ascrs/view/ASCRS-
Textbook- of- Colon- and- Rectal- Surgery/2285072/all/
Anastomotic_Construction.
55. Vignali A, Fazio VW, Lavery IC, etal. Factors associated with the occurrence of leaks in stapled rectal
anastomoses: a review of 1,014 patients. J Am Coll
Surg. 1997;185:105–13. https://doi.org/10.1016/
s1072- 7515(97)00018- 5.
56. Wang QY, Shi WJ, Zhao YR, et al. New concepts
in severe presacral hemorrhage during proctectomy. Arch Surg. 1985;120:1013–20. https://doi.
org/10.1001/archsurg.1985.01390330025005.
57. Weidenhagen R, Gruetzner KU, Wiecken T, et al.
Endoscopic vacuum-assisted closure of anastomotic
leakage following anterior resection of the rectum: a
new method. Surg Endosc. 2008;22:1818–25. https://
doi.org/10.1007/s00464- 007- 9706- x.
58. Wells CI, Vather R, Chu MJJ, et al. Anterior resection syndrome—a risk factor analysis. J Gastrointest
Surg. 2015;19:350–9. https://doi.org/10.1007/
s11605- 014- 2679- x.
59. Westerduin E, Klaver CEL, van Geloven AAW, etal.
Outcome after redo surgery for complicated colorectal and coloanal anastomosis: a systematic review.
Dis Colon Rectum. 2018;61:988–98. https://doi.
org/10.1097/DCR.0000000000001129.
60. Whitlow CB, Opelka FG, Gathright JB, Beck
DE.Treatment of colorectal and ileoanal anastomotic
sinuses. Dis Colon Rectum. 1997;40:760–3. https://
doi.org/10.1007/BF02055427.
61. Wu Z, van de Haar RCJ, Sparreboom CL, etal. Is the
intraoperative air leak test effective in the prevention of
colorectal anastomotic leakage? A systematic review
and meta-analysis. Int J Color Dis. 2016;31:1409–17.
https://doi.org/10.1007/s00384- 016- 2616- 4.
62. Yeung DE, Peterknecht E, Hajibandeh S, et al.
C-reactive protein can predict anastomotic leak in
colorectal surgery: a systematic review and metaanalysis. Int J Color Dis. 2021;36:1147–62. https://
doi.org/10.1007/s00384- 021- 03854- 5.
63. Zhou W, Xia L, Wang Z, et al. Transanal minimally invasive surgery for rectal anastomotic stenosis after colorectal cancer surgery. Dis Colon
Rectum. 2022;65:1062–8. https://doi.org/10.1097/
DCR.0000000000002361.
64. Zhu X-M, Yu G-Y, Zheng N-X, et al. Review of
Denonvilliers’ fascia: the controversies and consensuses. Gastroenterol Rep (Oxf). 2020;8:343–8.
https://doi.org/10.1093/gastro/goaa053.
Pelvic Radiation Therapy
SudhaAmarnath
37
Introduction
Radiation therapy is used frequently in the treatment of female pelvic malignancies, including
gynecologic, colorectal, and urologic cancers to
help improve local control and/or survival.
Radiation to the pelvis can be delivered using
external beam or brachytherapy techniques and
can be used in several different settings, often in
combination with pelvic surgery. The most common uses of radiation include (1) Denitive treatment of cancer (e.g., locally advanced cervical
cancer, medically inoperable endometrial cancer,
rectal cancer in the era watch and wait), (2)
Preoperative or neoadjuvant therapy for downstaging of a tumor to facilitate R0 resection and to
sterilize microscopic disease (e.g., locally
advanced rectal cancer, FIGO stage IIIB endometrial cancer), and (3) Postoperative or adjuvant
therapy to sterilize microscopic or gross residual
disease after surgery (e.g., FIGO stage III/IVA
endometrial cancer, node-positive cervix cancer
after radical hysterectomy). When radiotherapy is
sequenced with surgery, the surgical team must be
aware of the acute and late toxicities of radiation
treatment and the implications these may have on
their operation and the risk of peri- operative com-
S. Amarnath (*)
Department of Radiation Oncology, Cleveland Clinic
Foundation, Cleveland, OH, USA
plications. This chapter describes the major
potential toxicities of pelvic radiation therapy,
acute and late, by organ site. Strong communication between the radiation oncology and surgical
teams can help facilitate optimal timing of treatments and management of complications.
A Brief Primer onRadiation Therapy
External Beam Radiation Therapy
External beam radiation therapy (EBRT) most
typically involves using a linear accelerator to
deliver high-energy photons/x-rays to tissues in
the body. The photons interact with electrons and
water molecules to create free radicals that can
directly or indirectly damage the DNA of cells.
Biologically, cancer cells have less intact repair
mechanisms to repair the DNA damage, and thus
cancer cells die or become senescent, whereas
surrounding normal tissue cells are better able to
repair damage and can heal over time.
Unfortunately, because the radiation beams must
pass through normal tissues to get to the areas at
risk (Fig.37.1), inammation and acute damage
of surrounding normal tissues are common during and after treatment and are responsible for
many of the acute side effects of radiation treatment. Weeks to months after completion of radiation, some patients may develop chronic late
toxicities primarily related to scarring (e.g., bro-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_37
417
418
S. Amarnath
Fig. 37.1 An example pelvic radiotherapy plan using 3D-conformal radiation therapy to 45Gy in 25 fractions
sis, stenosis), chronic inammation (e.g., radiation proctitis/cystitis), or even tissue breakdown
(e.g., ulceration, stulae) [1]. Many of the side
effects of external beam radiation therapy are
dose-dependent and typically, the risk of toxicity
increases with increasing doses of radiation.
Modern radiation treatment planning techniques
can help to reduce the risks of many toxicities but
do not completely eliminate the risk of damage.
for gynecologic applications) is applied directly
to a tumor or tissue at risk. An advantage of
brachytherapy is that a smaller amount of normal tissue is exposed to radiation during the
treatment, which allows for dose escalation to
tumors for improved local control without as
much toxicity risk to surrounding normal tissues. The disadvantage of brachytherapy is that
it involves using applicators that are placed
directly into tissues at risk (e.g., vagina, cervix/
uterus, rectum), which requires a more invasive
Brachytherapy
procedure for the patient. The side effects of
brachytherapy can be similar to EBRT but are
Brachytherapy is a specialized form of radiation
where a radioactive source (typically Iridium-192
typically limited to smaller amounts of normal
tissue.
37 Pelvic Radiation Therapy
419
Radiotherapy Toxicity
The side effects of radiation therapy are typically
divided into three separate time points, acute,
sub-acute, and late. Acute side effects occur during or within a few weeks of completing treatment and are typically caused by inammation
and the death of rapidly proliferating cells in
normal tissue cells. Sub-acute side effects typically occur 4–12weeks after treatment and represent prolonged recovery from acute effects. Late
effects may occur months to years after treatment
and can include brosis, vascular injury, and
other gradual changes in more slowly dividing
tissues. Late effects may be irreversible and may
lead to end-organ damage. Any patient who
receives radiation treatment is at risk for the
development of a secondary malignancy due to
residual DNA damage. This is a rare effect of
treatment that, if it occurs, is most often seen
approximately 10–20years after treatment [2].
Several factors can inuence the risk of radiation toxicity incidence and severity. These include
radiation treatment factors such as the total dose
of radiation prescribed, dose per fraction, treatment schedule, volume of normal tissue exposed,
and number of years since prior radiation treatment (in the setting of re-irradiation). Patient factors can also inuence the risk of toxicity such as
smoking (a signicant predictor for late bowel
and bladder complications and can also decrease
the efcacy of treatment) [3], and vascular disorders such as diabetes and hypertension (increases
risk of effects from vascular injury and impacts
wound healing) [4, 5]. Obesity, low body mass
index, active collagen vascular disease, and
inammatory bowel disease may also increase
the risk of acute and late toxicities [5–8].
Toxicities by System
Bladder/Ureters/Urethra
Background
Radiation-induced bladder and urinary acute
effects are typically caused by inammation and
epithelial damage that leads to symptoms of dys-
uria, urgency, and increased frequency. Late toxicities are primarily due to epithelial and
microvascular changes mediated by brosis that
can lead to loss of compliance and capacity in the
bladder and ureteral and/or urethral stenosis, as
well as bleeding (radiation-induced hemorrhagic
cystitis), and stulae. Late effects typically arise
1–3years after radiation treatment and are typically less common than late GI effects [9–12].
Possible Eects
• Acute: Urinary frequency, urgency, dysuria.
• Late: Radiation cystitis leading to bleeding,
bladder dysfunction, ureteral/urethral stenosis/strictures, stulae.
Prevention
Bladder toxicity can be minimized with proper
radiation planning and delivery techniques to
decrease the volume of GU structures that are
irradiated, as well as decrease the volume of GU
tissues that receive high doses (e.g., treating with
full or empty bladder depending on clinical scenario, IMRT) [13].
Recognition
Patients typically present with signs/symptoms
consistent with the toxicities listed above.
Management
Acute side effects from pelvic XRT can typically
be managed with supportive care with medications as needed: dysuria (rule out urinary tract
infection, then cranberry, pyridium) and urgency/
frequency (e.g., oxybutynin, mirabegron). Late
side effects should typically be managed conservatively with uids, blood transfusions (as
needed), and bladder irrigation to remove clots.
Intravesical formalin and argon plasma coagulation can be tried at the time of cystoscopy. In
more refractory cases, Botox injection and hyperbaric oxygen may be helpful [14, 15]. Surgical
intervention is rarely indicated but may be helpful for urinary diversion in patients with vesicovaginal stulae. Ureteral/urethral dilation,
ureteral stent placement, urethrotomy, or open
surgery may be necessary for ureteral and urethral stenosis and strictures [1].
420
S. Amarnath
Small Bowel
Background
The small bowel is the tissue most susceptible to
damage within the pelvis during pelvic
XRT. Although both the small and large bowel
are at risk for toxicity, the small bowel is more
vulnerable to damage due to its high epithelial
mitotic rate, which leads to more acute side
effects. The acute injury can progress to focal
ischemia and brosis, which can lead to late
effects of ulcers, strictures, obstruction, and
bleeding [1]. The use of concurrent chemotherapy with radiation, such as 5-FU or capecitabine
(frequently used in the treatment of GI cancers),
can exacerbate these effects and cause enteritis of
their own accord [16]. Patients over the age of 60
are at increased risk of small bowel obstruction
or perforation [17]. Diabetes, atherosclerosis,
IBD, and prior abdominal surgery can also
increase the risk of toxicity.
Possible Eects
• Acute: diarrhea, bowel cramping, bloating,
increased gas.
• Late: radiation enteritis, malabsorption, small
bowel obstruction, bowel necrosis.
Prevention
Radiation effects on the small bowel can be
decreased in some patients with appropriate
treatment setup (full bladder, prone positioning
with belly board). If postoperative pelvic XRT is
planned or expected, mesh, omental, or other
aps can be used in the appropriate circumstance
to help minimize the amount of small bowel in
the pelvis [18, 19].
Recognition
Patients will typically present with signs or
symptoms of the effects listed above. Bowel wall
can be thickened and edematous on imaging.
tincture of opium), and other supportive medications (simethicone, dicyclomine). If the diarrhea is very severe, patients may require
inpatient admission for supportive care and, in
rare circumstances, may require the use of total
parenteral nutrition (TPN). Late effects may
also be managed conservatively with the supportive medications listed above but may
require surgical intervention for small bowel
obstructions and bowel necrosis. Patients with
malabsorption may require vitamin replacement (esp. vitamin B12) or bile salt replacement [20].
Colon/Rectum
Background
Radiation toxicity in the large bowel/rectum is
due to a similar mechanism of action as damage
to the small bowel. Mucosal atrophy and loss of
mucin-producing goblet cells contribute to possible late toxicities of treatment. Vascular
sclerosis can lead to mucosal telangiectasias or
ulceration more commonly in the colon and
rectum than in the small bowel [5, 21].
Possible Eects
• Acute: Diarrhea, increased urgency/frequency,
increased gas, mucositis → tenesmus and
pain, cramping, hemorrhoidal irritation.
• Late: Radiation proctitis leading to changes in
bowel habits, bleeding, ulceration, stulae.
Prevention
Modern XRT treatment planning (intensity modulated radiation therapy-IMRT) can help avoid
high doses to the rectum when it is not necessary
for treatment (e.g., many gynecologic cancers,
prostate cancers). Hydrogel spacers can help
minimize rectal dose in the appropriate patient
[13].
Management
Patients are typically managed conservatively
in the acute setting with uids, anti-diarrheal
agents (loperamide, diphenoxylate/atropine,
Recognition
Patients often present with diarrhea or bright red
blood per rectum. Radiation proctitis can also be
recognized on endoscopic exams (Fig.37.2).
6 months p XRT18 months p XRT
37 Pelvic Radiation Therapy
Fig. 37.2 Endoscopic images of radiation proctitis (6months and 18months after pelvic radiotherapy)
421
Management
Diarrhea is managed with uids and antidiarrheal agents as noted in small bowel section above. Hemorrhoids are managed
conservatively with topical ointments.
Symptomatic late radiation proctitis can be
managed with enemas (sucralfate, hydrocortisone, and rebamipide can help protect injured
mucosa) or with topical formalin or argon
plasma coagulation (APC) at the time of colonoscopy [19]. Hyperbaric oxygen therapy may
be helpful in more refractory cases [14, 22].
Diverting ostomy may be necessary in patients
with recto-vaginal stulas due to tumor or
treatment.
Anus/Vulva/Skin
Background
The anus, anal margin, and vulvar are tissues that
are susceptible to the acute and late effects of
radiation primarily due to injury of the epithelial
and deeper dermal layers of the skin and mucosa.
Smoking, diabetes, and peripheral vascular disease can increase the risk of skin toxicity and
impair long-term healing [1]. Scleroderma
patients can also suffer from increased brosis
and skin toxicity with radiation treatment.
Obesity can increase the risk of toxicity due to
higher doses of radiation delivered due to overlapping skin folds (i.e. pannus).
Possible Eects
• Acute: pain, itching, yeast infections.
Radiation dermatitis (dryness, redness,
desquamation).
• Late: Sphincter dysfunction, incontinence,
stenosis, labial adhesions, dyspareunia, sexual
dysfunction, scarring, brosis, hyperpigmentation, pain.
Prevention
Skin sparing can be achieved in most cases with
modern radiation technology. When the anus,
vulva, or groins must be targeted, using a frog leg
setup can help minimize skin folds to decrease
radiation dermatitis to the upper legs.
Recognition
Radiation dermatitis typically progresses from
dry skin (often with associated itching) to redness/hyperpigmentation, and then peeling of the
epithelial and dermal layers. This is often
extremely painful.
Management
Skin toxicity is managed primarily with topical creams and ointments. Water/petroleumbased products can help provide a moisture
422
S. Amarnath
barrier for healing and are safe for use during
treatment. Aloe vera, witch hazel, topical
anesthetics, and Sitz baths can also provide
symptomatic relief. Zinc oxide and silver sulfadizene may be helpful after treatment [23].
Patients with non- healing ulcers should be
referred to wound care specialists and may
benefit from HBOT [22, 24]. Radiation fibrosis can be challenging to manage but can
sometimes be treated with massage, oral pentoxifylline, and vitamin E [25, 26]. Patients
with anal or vulvar adhesions or stenosis
should be referred to colorectal surgery and
urogynecology respectively.
Uterus
Background
Damage to the uterus from pelvic XRT is primarily due to late brosis causing decreased
growth and compliance, as well as microvascular
changes and arteriolar damage that leads to
decreased fetoplacental blood ow [1]. These
changes are dose-dependent—patients receiving
lower doses of pelvic radiation may be able to
carry a future pregnancy with increased risks;
patients receiving more standard dosing of
45–50Gy of XRT are unlikely to be able to carry
a future pregnancy and typically will require a
gestational carrier [27].
Possible Eects
• Acute: cramping with brachytherapy
procedures.
• Late: altered blood ow and brosis → infer-
tility/inability to carry a pregnancy, miscarriage, preterm labor, low birth weight, and
placenta accreta.
Prevention
At this time, there are very few options to prevent
radiation dosing to the uterus given its central
pelvic location. Uterine transposition (moving
the uterus with its associated blood supply out of
the pelvis during radiation) is considered experimental [28].
Recognition
There are typically no symptoms associated with
uterine late effects from radiation. If a patient
has a history of prior pelvic XRT and is interested in pregnancy, they should be referred to
reproductive endocrinology and infertility (REI)
specialists and maternal-fetal medicine (MFM)
specialists to help discuss options.
Management
Patients should be counselled on risks prior to
pelvic XRT and referred to the appropriate specialists as needed. Referral to behavioral health
specialists may also be benecial for appropriate
patients.
Ovaries
Background
The ovaries are exquisitely sensitive to radiation
and loss of 50% of oocytes is seen at doses as low
as 2–4Gy. Long-term ovarian shutdown is both
age and dose-dependent but is expected in women
of all ages with more standard pelvic dosing used
for pelvic malignancies (45–50Gy) [29, 30].
Possible Eects
• Acute: none.
• Late: infertility, premature ovarian insufciency (POI) → impact on cardiovascular,
mental, neurologic, vaginal, and musculoskeletal health.
Prevention
Patients should be referred to REI prior to initiating pelvic XRT to discuss possible cryopreservation of embryos, oocytes, or ovarian tissue [29].
Laparoscopic ovarian transposition (moving the
ovary (ies) with vascular pedicle outside the pelvis) is also a good option for well-selected
patients under the age of 40 and may be performed at the time of other surgeries (i.e. nodal
debulking/sampling). Ideally, ovaries should be
transposed as high and lateral as possible in the
abdomen and a minimum of 3cm from the edge
of the expected radiation treatment eld [31].
37 Pelvic Radiation Therapy
423
Recognition
Patients will typically present with symptoms of
menopause, including amenorrhea, hot ashes,
mood changes, and fatigue. Hormone levels
(FSH, E2) should be checked to assess for POI.
Management
Proper counselling and referrals prior to initiating pelvic XRT are of the utmost importance
since none of the preventive measures outlined
above can be performed after treatment has
started. Women experiencing POI should be
referred to a Women’s Health and behavorial
health specialist for discussion of possible hormone replacement therapy (HRT) if under age 40
and possible symptomatic treatment of hot
ashes (e.g., venlafaxine, fezolinetant).
Vagina
Background
Vaginal effects from pelvic XRT are similarly
due to epithelial and mucosal changes as
described for other organs above [32]. These
changes may lead to a diminishment of sexual
function and quality of life [33].
Possible Eects
• Acute: increased vaginal discharge, mucositis, pain, itching, dryness, yeast infection.
• Late: brosis, ulceration, teleangiectasias, stenosis, dryness, discharge, adhesions, dyspareunia, sexual changes/dysfunction.
Prevention
Although prospective data is limited, national
and international guidelines recommend the use
of vaginal dilators to help mitigate the late
adverse effects of radiation on the vaginal.
Dilators help decrease adhesions and maintain
the elasticity of the tissue. Lubrication with coconut oil or other vaginal moisturizers should be
used to help with vaginal dryness [34].
Recognition
Patients may notice vaginal pain, dryness, dyspareunia, and/or vaginismus. Adhesions, loss of
elasticity, vascular changes, and dryness after
radiation may be appreciated on pelvic
examination.
Management
Vaginal dilators per above. Appropriate
patients may benet from topical estrogen
creams. Referral to urogynecology for dilation
and surgical management of adhesions may be
appropriate. Sexual health and behavioral
health specialists may also be helpful [35].
Vitamin E, pentoxifylline, and hyperbaric oxygen may be appropriate for soft tissue necrosis
of the vagina [22, 24–26]. Fistulas that develop
between the vagina and bladder or vagina and
rectum typically require surgical diversion and
management.
Vascular/Lymphatics/Nerves
Background
Radiation may also have long-term effects on the
vascularity of the pelvis (as noted in multiple
organ systems above) that may also impair wound
healing and lead to wound healing complications
[1, 36]. Fibrosis of the lymphatic tissues (especially with groin irradiation) can lead to lymphedema of the legs. The nerves are quite resistant
to radiation damage, but with higher doses of
radiation (often seen with stereotactic body
radiotherapy-SBRT, re-irradiation, or intraoperative radiotherapy-IORT), damage to the peripheral nerves is possible.
Possible Eects
• Acute: impaired blood ow → wound healing
delays.
• Late: impaired blood ow → wound healing
delays, lymphedema, peripheral neuropathy
(numbness, tingling, pain).
Prevention
Accurate contouring and delineation of the
nerves and the use of IMRT techniques may help
reduce high-dose radiation to peripheral nerves.