Abstract
Purpose
This study investigated late urinary adverse events (UAEs) in patients who underwent pelvic radiation therapy, with a focus on occurrence, diagnostic characteristics and the impact of subsequent extirpative surgery with the need of urinary diversion on quality of life.
Methods
A retrospective analysis of 20 patients after pelvic radiotherapy (2016–2022) was conducted. Data included demographics, perioperative details, oncological parameters, and patient-reported outcomes. Imaging (CT, MRI) was examined for early manifestations of late UAEs.
Results
In the study cohort, prostate cancer was the primary malignancy in 85% with a mean radiation dose of 84 Gray over 35 days. Time to diagnosis of late UAEs was 4.0 years post-radiation. Radiological assessment demonstrated a progressive increase in typical CT and MRI features of pubic bone osteomyelitis over time. Surgical interventions, mainly cystectomy, were required with variable outcomes in patient-reported post-surgery quality of life.
Conclusion
Diagnosing and managing late UAEs after pelvic radiation necessitate an understanding of their occurrence, diagnostic features and appropriate management strategies. Early imaging, particularly MRI, is crucial for timely diagnosis and treatment planning. Variable post-surgery quality of life underscores the importance of a multidisciplinary approach in managing late UAEs. The study contributes to understanding these complications and emphasizes their consideration in post-radiation follow-up care.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00345-024-05155-2.
Keywords: Pubic bone osteomyelitis, Urosymphyseal fistula, Pelvic radiation therapy, Cystectomy, Complications
Introduction
Adjuvant radiation therapy after surgical treatment of urological cancer and primary radiation as curative therapy measures are established therapeutic treatment methods in urological oncology [1–3]. Early detection through improved diagnostic technologies have significantly improved post-diagnosis survival rates. A multidisciplinary approach involving conservative, surgical, and radiation therapies has played a key role [4]. Radiotherapy is estimated to be a highly effective cytotoxic therapy for localized solid malignancies, forming a crucial part of cancer treatment for approximately 50% of all cancer patients [5–7]. One of the disadvantages of radiotherapy is the affection of both cancer and healthy cells in the treated area. As a consequence and due to the anatomy of the pelvis, urological complications occur not only after radiotherapy of urological malignancies but also after radiotherapy of the digestive and reproductive system [8]. Late urinary adverse events (UAEs), such as urosymphyseal fistulas and pubic bone osteomyelitis can occur many years after the initial radiation treatment [9–12]. These burdensome complications present with chronic and unrelenting pubic pain and recurrent urinary tract infections. Although these UAEs are comparatively rare, they can be very serious and significantly degrade quality of life (QoL). Urosymphyseal fistulas and pubic bone osteomyelitis often cannot be treated conservatively, but require major surgical interventions, such as resection of the pubic symphysis, cystectomy and urinary diversion or complicated reconstruction techniques [12–14]. Due to the impaired tissue healing after radiotherapy the surgical treatment of those complications may be a challenge for urologists [12, 15]. Lavien et al. showed improved pain outcomes in patients undergoing surgery for pubic bone osteomyelitis compared to conservative therapy [16].
In general, however, outcomes in these patients, such as health-related quality of life and emotional aspects after definitive surgery are not well described to date.
Despite advancements in radiotherapy reducing radiation damage, late UAEs still occur. Computed tomography (CT) or magnetic resonance imaging (MRI) are necessary diagnostic tools when late UAEs after radiotherapy are clinically suspected [17–19]. However, there is a lack of standardized imaging criteria for an early detection of UAEs [20]. The aim of this study was to assess the natural course of UAEs following pelvic radiation therapy, analyzing radiation dosage, time frames for symptom onset and management of UAEs. Additionally, we aimed to analyze early radiographic manifestations of UAEs and assess QoL following therapeutic interventions involving the urinary tract. By addressing the mentioned aspects, we seek to contribute to a deeper understanding of these complications and hence, to an adequate treatment decision-making.
Material and methods
Study population and data collection
Data of 20 patients from a German high-volume tertiary referral university hospital, who underwent pelvic exenteration including cystectomy after radiation therapy of the pelvic region between 2016 and 2022, were retrospectively evaluated. Surgery was only performed for chronic and intractable pubic pain and recurrent urinary tract infections, with the aim of relieving symptoms. None of the patients underwent surgery for tumour recurrence. The collected data included demographic and perioperative parameters, information about the primary malignancy, radiotherapy type, cumulative radiation dose, timing and duration of radiotherapy. Additionally, prospective analysis included health-related quality of life and emotional impact assessed through the EORTC QLQ-C30 and the decision regret scale (DRS) [21, 22]. The EORTC QLQ-C30 assesses functional scales, symptom scales and overall QoL/global health status in a 30-item questionnaire. The scores range from 0 to 100. A high score for functional scales and overall QoL/global health status represents a high level of functioning and QoL, whereas high scores for symptom scales represent high levels of symptomatology. The DRS is a 5-item questionnaire and measures decision regret on a 0–100 scale, where 0 indicates no regret and 100 signifies high regret.
Radiological assessment
Available sectional radiographic imaging (CT and MRI) was assessed by two uro-radiologists. Three time points of imaging were of interest: (1) after radiotherapy and before onset of symptoms, (2) at first onset of symptoms, (3) preoperatively. One of the radiologists was blinded concerning the date of the imaging. Both radiologists were blinded to the extent of the patient's complaints, but not to the diagnosis itself. The analysis was performed to classify characteristic correlates for pubic bone osteomyelitis, such as pubic bone marrow edema, cleft sign in the pubic symphysis, sclerosis, effusion of the pubic symphysis and pubic bone erosion. Depending on the specific manifestation of those characteristics, points from one (no alteration) to five (very distinct changes) were allotted and a sum score generated. The score ranged from 1 (no signs of pubic bone osteomyelitis) to 5 (very distinct signs of pubic bone osteomyelitis).
Surgical technique
Extirpative surgery involved the removal of the urinary bladder and the prostate in men. In one case ureteral clipping without cystectomy was performed. Whenever necessary, surgical debridement or resection of the pubic symphysis were performed by an orthopedist. Temporary external fixation was used to stabilize the pelvic ring. In some cases, fistula excision was combined with omentoplasty or protective ileostomy. Omental flaps were attached to fix or fill defects.
Statistical analysis
All statistical analyses were performed using statistical software JMP® from SAS (version 13 for Windows, SAS Institute Inc.) and GraphPad Prism 5.0 (GraphPad Software Inc., La Jolla, CA, USA). For descriptive statistics, mean and standard deviation or median and interquartile range (IQR) were calculated. EORTC QLQ-C30 results were compared to established thresholds for clinical importance of the features to facilitate the interpretation of the results [23].
Results
In this study n = 27 patients were initially screened for inclusion, of which n = 20 were included in the final analysis. Four patients were excluded due to lack of pelvic radiation, one patients due to diagnosis of fistula before radiation and two patients due to only conservative treatment (see Supplementary Fig. 1). At the time of the prospective data collection four patients had died, one patient suffered dementia, two patients could not be contacted and one patient did not want to take part in the data collection. Hence, 12 patients could be included in this part of the study.
The median duration of the radiation therapy in our cohort was 35 (34–41) days and the median radiation therapy dose was 75 (73–99) Gy. The median time from radiation therapy to diagnosis of pubic bone osteomyelitis and/or fistulas was 4.0 (0.9–6.5) years. The median time from first occurrence of symptoms until definitive surgery was 5.0 (1.7–15.5) months. Pubic bone osteomyelitis could be detected in 13 patients (65%) in the preoperative imaging and/or during surgery, fistulas could be observed in 19 patients (95%).
All patients underwent cystectomy or ureteral clipping, 10 patients (50%) underwent additional resection of the pubic symphysis or at least a surgical debridement of the pubic symphysis and eight patients (40%) needed an external fixation for stabilization of the pelvic ring. Temporary urinary diversion via urethral catheter or suprapubic tube before development of fistulas and/or pubic bone osteomyelitis was observed in 10 patients (50%). Preoperative urine cultures identified in 88% of the patients relevant levels of bacteria. Intraoperative microbiological smears of the pubic symphysis detected germs in 67% of the patients. Detailed demographic and clinical patient characteristics are summarized in Table 1
Table 1.
Baseline demographics and clinical characteristics of the study population (n = 20)
| Age in years, median (IQR) | 73 (69–78) |
| Male, n (%) | 19 (95) |
| ASA, median (IQR) | 3 (2–3) |
| BMI kg/m2, median (IQR) | 27.5 (25.3–31.0) |
| Basic oncological disease, n (%) | |
| Prostate cancer | 17 (85) |
| Colorectal cancer | 1 (5) |
| Anal cancer | 1 (5) |
| Cervical cancer | 1 (5) |
| Duration of radiation therapy (days), median (IQR) | 35 (34–41)a |
| Cumulative dose of radiation (Gray), median (IQR) | 75 (73–99)a |
| Type of radiation therapy, n (%) | |
| External beam radiation | 19 (95) |
| Brachytherapy | 1 (5) |
| Time from radiation to diagnosis (years), median (IQR) | 4.0 (0.9–6.5)b |
| Time from first symptoms to diagnosis (months), median (IQR) | 1.0 (1.0–1.0) |
| Time from first symptoms to surgery (months), median (IQR) | 5.0 (1.7–15.5)a |
| Type of complication, n (%) | |
| Pubic osteomyelitis | 13 (65) |
| Fistula | 19 (95) |
| History of urinary catheter, n (%) | 10 (50) |
| Preceding endoscopic treatment, n (%) | 15 (75) |
| Transurethral incision | 7 (35) |
| TURP | 5 (25) |
| Bladder neck incision/resection | 1 (5) |
| Artificial urinary sphincter implantation/explantation | 3 (15) |
| Positive microbiological results, n (%) | |
| Urinary culture | 15 (88)a |
| Smear of pubic symphysis | 8 (67)c |
|
Surgical treatment, n (%) Cystectomy/ureteral clipping |
20 (100) |
| Pubic bone resection/debridement | 10 (50) |
| External fixation | 8 (40) |
| Urinary diversion, n (%) | |
| Ileal conduit | 19 (95) |
| Ureteral clipping and percutaneous nephrostomy | 1 (5) |
TURP transurethral resection of the prostate
aData of 3 patients missing
bData of 1 patients missing
cData of 8 patients missing
In most patients (85%) prostate cancer was the underlying oncological disease that led to pelvic radiotherapy at some point in the therapy sequence (see Supplementary Fig. 2).
Patient-reported distress or remorse after the decision to undergo cystectomy revealed a mean DRS of 18 (± 19) points. The distribution of the scores is illustrated in Fig. 1a.
Fig. 1.
Results of the decision regret scale (a) and of the EORTC QLQ-C30 (b), red lines indicting thresholds for clinical importance; data of 8 patients missing
Evaluation of QoL, symptom and functional scales showed that nausea/vomiting, loss of appetite, insomnia and constipation were less pronounced after cystectomy and below the threshold for clinical significance, whereas physical and role functioning and symptoms such as fatigue, pain, dyspnoea and diarrhoea seemed to be more affected after cystectomy, as they occurred more frequently compared to the established thresholds for clinical importance. Overall QoL/global health status, functional and symptom scales of the EORTC QLQ-C30 are shown in Fig. 1b. The thresholds for clinical importance of the functional and symptom scales are marked in the figure [23]. The questionnaires were completed on average 23 months after cystectomy.
The results of the radiological image analysis showed a mean point score of 1.1 points in the imaging after radiotherapy and before onset of symptoms, 2.2 points after first occurrence of symptoms and 3.3 points in the imaging before reconstructive surgery. Both radiologists assigned the same point score for the imaging after radiotherapy and before first occurrence of symptoms and after beginning of first symptoms. Only in the imaging before definitive surgery the assigned points differed slightly (3.2 vs.3.5 points, see Supplementary Fig. 3). Figure 2 illustrates MR imaging of a patient with pronounced signs of acute pubic bone osteomyelitis.
Fig. 2.
76-year old male patient with acute pubic bone osteomyelitis. a Coronal T2/STIR and b axial T2 TSE fs images depict marked bilateral edema of the pubic bones and widening of the symphyseal cleft with fluid collection. c Coronal T1 non-fat sat and d axial T1 fat-sat post-contrast images yield diffuse bilateral contrast enhancement of the pubic bone, of the adductor muscle group and of the internal obturator muscle. These findings are in keeping with pronounced acute pubic bone osteomyelitis, the patient received an overall score of 5 in the radiological read and subsequent symphyseal resection
Discussion
Due to an aging society and improved cancer therapy, more patients undergo pelvic radiation for tumors during long-term survivorship. Consequently, there's a rising incidence of late UAEs post-pelvic radiation [8]. Pelvic osteomyelitis and urosymphyseal fistulas in this context are rare, with poorly documented incidence and prevalence. Most pre-2010 studies were limited case series. According to German health insurance data, 5.7% of patients receiving pelvic radiation for tumors between 2010 and 2017 developed late UAEs.
Patients with these complications often undergo prolonged multimodal treatments, where conservative approaches prove ineffective. The transition to radical therapy through cystectomy and urinary diversion is delayed, reflecting years of suffering. In our cohort, 95% opted for cystectomy with ileal conduit, while 5% chose bladder-sparing surgery. Additional pubic bone resection was performed in 50% and 40% required debridement with external fixation, aligning with prior studies favoring cystectomy for post-pelvic radiation fistulas and pubic bone osteomyelitis [24].
Following a median radiation duration of 35 (34–41) days, mirroring the standard external beam radiation therapy for prostate cancer, our cohort showed time frames of 4.0 (0.9–6.5) years from radiotherapy completion to diagnosis, 1.0 (1.0–1.0) months from symptom onset to diagnosis and 5.0 (1.7–15.5) months from symptom onset to definitive surgical therapy. This latency, ranging from years to over a decade, is consistent with findings from Toia et al., reporting a median 6-year interval to primary urological reconstructive surgery post-pelvic radiation [12, 25]. Faris et al. observed a median 4.6-year duration from radiation therapy to symptom presentation in prostate cancer patients [26]. Our median cumulative pelvic radiation dose 75 (73–99) Gy aligns with standard therapy for prostate cancer, as seen in studies reporting comparable doses [27]. However, variations in doses, treatment schedules, and follow-up durations across studies limit direct comparisons regarding the toxic effects of the applied radiation dose.
Temporary urinary diversion and a history of endoscopic treatments are recognized risk factors for complications post-pelvic radiation. In our cohort, 75% underwent urethral manipulations, aligning with Andrews et al.’s findings [28]. Cystectomy is often the preferred medical choice, with patient-reported outcomes revealing no regrets and 36% of the patients of our cohort having no doubts at all that cystectomy was the right decision. No patient showed a score of more than 50 in the DRS which is underlining the tendency towards the patients’ well-being after cystectomy. Functional outcomes vary, with cognitive and emotional functioning showing improvement, while physical and role functioning may be more affected. Symptoms post-cystectomy exceed clinical thresholds in fatigue, nausea, pain, dyspnea, and diarrhea, while appetite loss, insomnia, and constipation are less pronounced. These findings partly align with studies reporting enhanced postoperative functional status, reduced pelvic pain, and improved pain scores [10, 16, 24, 25, 28]. Andrews et al. demonstrated significant postoperative functional status restoration [28]. Our cohort's assessment, with a median time of 25 months between cystectomy and EORTC QLQ-C30 evaluation, may reflect additional comorbidities. Cognitive and emotional outcomes align with stable mental health post-cystectomy in prostate cancer survivors [25].
Our radiological assessment demonstrated a progressive increase in the score over time. Pre-symptomatic CT and MRI scans exhibited minimal tissue and bone alterations. Upon symptom onset, imaging revealed tissue changes consistent with pubic bone inflammation, resulting in an elevated score. Imaging immediately before surgery depicted the highest score, signifying a progression in specific alterations. Radiographically, MRI emerged as the most precise technique for detecting changes consistent with pubic bone osteomyelitis and urosymphyseal fistulas [19, 20, 29, 30]. While CT scans reveal osseous changes and signs of chronic osteomyelitis, they are less sensitive than MRI due to decreased soft tissue contrast [19]. Nevertheless, CT contributes valuably to rapid diagnosis, given its detectable osteomyelitis characteristics and faster availability compared to MRI. Our data underscore the notion that early imaging, particularly MRI, serves as a reliable diagnostic tool for suspected pelvic osteomyelitis, facilitating optimal surgical planning. Implementing a point score for CT and MR scans could assist in classifying pubic bone osteomyelitis severity, expediting definitive treatment. Radiologists engaged in such cases should be well-acquainted with the imaging features of late UAEs and anticipated post-treatment findings.
Our study is not exempt from limitations, with the primary constraint being the modest sample size, which can compromise the representativeness and generalizability of our findings. The absence of a control group poses another limitation, and its inclusion would augment internal validity by mitigating the impact of confounding variables. Additionally, limited blinding during radiological assessment introduces potential bias in CT and MRI scan scoring. Furthermore, our reliance on data from a solitary German health insurance company, with a three-year follow-up, may underestimate late UAE occurrences beyond this period. Despite these limitations, our study contributes valuable insights into the trajectory, diagnosis, and management of late UAEs post-pelvic radiation.
Conclusion
The diagnosis of pubic bone osteomyelitis and urosymphyseal fistulas after radiotherapy of the pelvic region requires a high index of suspicion and an accurate and thorough evaluation. Conducting an extensive diagnostic workup, including early imaging followed by accurate assessment of the typical characteristics of pubic bone osteomyelitis, reduces the time frame to diagnosis and to definitive treatment. Thereby, long suffering could be prevented and QoL preserved. Interdisciplinary follow-up care, including urological assessment, after pelvic radiation of also non-urological tumors, should be standard and multidisciplinary therapy approaches are crucial for a successful management of these complications.
Supplementary Information
Below is the link to the electronic supplementary material.
Supplementary file1 Supplementary Fig. 1 Flow chart of exclusion criteria and cohort size (PDF 210 KB)
Supplementary file2 Supplementary Fig. 2 Therapy sequences of the cohort; RPX = radical prostatectomy, XRT = (pelvic) radiation therapy, HIFU = high-intensity focused ultrasound, LAR = low anterior resection, LAE = pelvic lymphadenectomy; *anal cancer as primary disease, #colorectal cancer as primary disease, +cervical cancer as primary disease (PDF 201 KB)
Supplementary file3 Supplementary Fig. 3 Results of the radiological assessment of CT and MRI scans of the study cohort performed by both radiologists (a+b) (PDF 206 KB)
Acknowledgements
We thank all patients who participated in the study.
Abbreviations
- ASA
American Society of Anesthesiologists
- BMI
Body mass index
- CI
Confidence interval
- CT
Computed tomography
- Gy
Gray
- IQR
Interquartile range
- MRI
Magnet resonance imaging
- QoL
Quality of life
- SD
Standard deviation
- UAE
Urinary adverse event
Author contributions
MT Walach: protocol/project development, data analysis, manuscript writing/editing, AA Tavakoli: data analysis, critical revision and scientific input, G Thater: data analysis, critical revision and scientific input, MC Kriegmair: critical revision and scientific input, MS Michel: critical revision and scientific input, MC Rassweiler-Seyfried: protocol/project development, data analysis, manuscript writing/editing.
Funding
Open Access funding enabled and organized by Projekt DEAL.
Data availability statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
Declarations
Conflict of interest
The authors declare no conflict of interest.
Statement of ethics
The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. University of Heidelberg’s Ethics Committee II, Medical Faculty Mannheim, reference number 2022-801-MA and 2022-592-MA. All written informed consent was obtained from the participants to participate in the study and for publication of the details of their medical case.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M et al (2021) EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 79(2):243–262 [DOI] [PubMed] [Google Scholar]
- 2.Cornford P, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch MG, De Santis M et al (2021) EAU-EANM-ESTRO-ESUR-SIOG guidelines on prostate cancer. Part II-2020 update: treatment of relapsing and metastatic prostate cancer. Eur Urol 79(2):263–282 [DOI] [PubMed] [Google Scholar]
- 3.Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G et al (2021) European Association of Urology guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2020 guidelines. Eur Urol 79(1):82–104 [DOI] [PubMed] [Google Scholar]
- 4.Miller KD, Siegel RL, Lin CC, Mariotto AB, Kramer JL, Rowland JH et al (2016) Cancer treatment and survivorship statistics, 2016. CA Cancer J Clinicians 66(4):271–289 [DOI] [PubMed] [Google Scholar]
- 5.Baskar R, Lee KA, Yeo R, Yeoh KW (2012) Cancer and radiation therapy: current advances and future directions. Int J Med Sci 9(3):193–199 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Delaney G, Jacob S, Featherstone C, Barton M (2005) The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 104(6):1129–1137 [DOI] [PubMed] [Google Scholar]
- 7.Begg AC, Stewart FA, Vens C (2011) Strategies to improve radiotherapy with targeted drugs. Nat Rev Cancer 11(4):239–253 [DOI] [PubMed] [Google Scholar]
- 8.Elliott SP, Malaeb BS (2011) Long-term urinary adverse effects of pelvic radiotherapy. World J Urol 29(1):35–41 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Bugeja S, Andrich DE, Mundy AR (2016) Fistulation into the pubic symphysis after treatment of prostate cancer: an important and surgically correctable complication. J Urol 195(2):391–398 [DOI] [PubMed] [Google Scholar]
- 10.Gupta S, Zura RD, Hendershot EF, Peterson AC (2015) Pubic symphysis osteomyelitis in the prostate cancer survivor: clinical presentation, evaluation, and management. Urology 85(3):684–690 [DOI] [PubMed] [Google Scholar]
- 11.Matsushita K, Ginsburg L, Mian BM, De E, Chughtai BI, Bernstein M et al (2012) Pubovesical fistula: a rare complication after treatment of prostate cancer. Urology 80(2):446–451 [DOI] [PubMed] [Google Scholar]
- 12.Toia B, Seth J, Ecclestone H, Pakzad M, Hamid R, Greenwell T et al (2019) Outcomes of reconstructive urinary tract surgery after pelvic radiotherapy. Scand J Urol 53(2–3):156–160 [DOI] [PubMed] [Google Scholar]
- 13.Kocot A, Riedmiller H (2015) Treatment of long-term radiation injuries in the urinary tract. Der Urologe Ausg A 54(12):1765–1771 [DOI] [PubMed] [Google Scholar]
- 14.Lobo N, Kulkarni M, Hughes S, Nair R, Khan MS, Thurairaja R (2018) Urologic complications following pelvic radiotherapy. Urology 122:1–9 [DOI] [PubMed] [Google Scholar]
- 15.Stone HB, Coleman CN, Anscher MS, McBride WH (2003) Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol 4(9):529–536 [DOI] [PubMed] [Google Scholar]
- 16.Lavien G, Chery G, Zaid UB, Peterson AC (2017) 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 100:234–239 [DOI] [PubMed] [Google Scholar]
- 17.Wignall TA, Carrington BM, Logue JP (1998) Post-radiotherapy osteomyelitis of the symphysis pubis: computed tomographic features. Clin Radiol 53(2):126–130 [DOI] [PubMed] [Google Scholar]
- 18.Semelka RC, Hricak H, Kim B, Forstner R, Bis KG, Ascher SM et al (1997) Pelvic fistulas: appearances on MR images. Abdom Imaging 22(1):91–95 [DOI] [PubMed] [Google Scholar]
- 19.Pineda C, Espinosa R, Pena A (2009) Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg 23(2):80–89 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sexton SJ, Lavien G, Said N, Eward W, Peterson AC, Gupta RT (2019) Magnetic resonance imaging features of pubic symphysis urinary fistula with pubic bone osteomyelitis in the treated prostate cancer patient. Abdom Radiol (N Y) 44(4):1453–1460 [DOI] [PubMed] [Google Scholar]
- 21.Brehaut JC, O’Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E et al (2003) Validation of a decision regret scale. Med Decis Mak Int J Soc Med Decis Mak 23(4):281–292 [DOI] [PubMed] [Google Scholar]
- 22.Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ et al (1993) The European Organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85(5):365–376 [DOI] [PubMed] [Google Scholar]
- 23.Giesinger JM, Loth FLC, Aaronson NK, Arraras JI, Caocci G, Efficace F et al (2020) Thresholds for clinical importance were established to improve interpretation of the EORTC QLQ-C30 in clinical practice and research. J Clin Epidemiol 118:1–8 [DOI] [PubMed] [Google Scholar]
- 24.Anele UA, Wood HM, Angermeier KW (2022) Management of urosymphyseal fistula and pelvic osteomyelitis: a comprehensive institutional experience and improvements in pain control. Eur Urol Focus 8(4):1110–1116 [DOI] [PubMed] [Google Scholar]
- 25.Inouye BM, Krischak MK, Krughoff K, Boysen WR, Peterson AC (2022) Resection of pubic symphysis and cystectomy significantly improves short-term patient-reported physical functioning among patients with pubovesical fistula and pubic bone osteomyelitis. Urology 167:218–223 [DOI] [PubMed] [Google Scholar]
- 26.Faris SF, Milam DF, Dmochowski RR, Kaufman MR (2014) Urinary diversions after radiation for prostate cancer: indications and treatment. Urology 84(3):702–706 [DOI] [PubMed] [Google Scholar]
- 27.Michalski JM, Moughan J, Purdy J, Bosch W, Bruner DW, Bahary JP et al (2018) Effect of standard vs dose-escalated radiation therapy for patients with intermediate-risk prostate cancer: the NRG oncology RTOG 0126 randomized clinical trial. JAMA Oncol 4(6):e180039 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Andrews JR, Hebert KJ, Boswell TC, Avant RA, Boonipatt T, Kreutz-Rodrigues L et al (2021) Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment. BJU Int 128(4):460–467 [DOI] [PubMed] [Google Scholar]
- 29.Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G (2016) The imaging of osteomyelitis. Quant Imaging Med Surg 6(2):184–198 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Lachi PK, Patnaik S, Amit K, Naidu KV (2015) Imaging findings after radiotherapy to the pelvis. J Cancer Res Ther 11(3):545–548 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary file1 Supplementary Fig. 1 Flow chart of exclusion criteria and cohort size (PDF 210 KB)
Supplementary file2 Supplementary Fig. 2 Therapy sequences of the cohort; RPX = radical prostatectomy, XRT = (pelvic) radiation therapy, HIFU = high-intensity focused ultrasound, LAR = low anterior resection, LAE = pelvic lymphadenectomy; *anal cancer as primary disease, #colorectal cancer as primary disease, +cervical cancer as primary disease (PDF 201 KB)
Supplementary file3 Supplementary Fig. 3 Results of the radiological assessment of CT and MRI scans of the study cohort performed by both radiologists (a+b) (PDF 206 KB)
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.