Does Pelvic Radiotherapy Affect Genitourinary Function in Patients After Abdominoperineal Resection for Distal Rectal Cancer?
Michael S. Kasparek*1,4, Imran Hassan2, Robert R. Cima1, Dirk R. Larson3, Rachel E. Gullerud3, Bruce G. Wolff1
1Division of Colon and Rectal Surgery, Mayo Clinic Rochester, Rochester, MN; 2Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL; 3Section of Biostatistics, Mayo Clinic Rochester, Rochester, MN; 4Department of Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
Objective
Abdominoperineal resection (APR) as well as radiotherapy (XRT) have detrimental effects on urinary and sexual function, but little is known about effects of XRT in APR patients specifically. Therefore, our aim was to investigate potential effects of XRT on genitourinary function in APR patients.
Methods
International Consultation on Incontinence Questionnaire (ICIQ), American Urological Association Symptom Index (AUASI), Brief Sexual Function Inventory (BSFI) for men, and sexual function module of the Cancer Rehabilitation Evaluation System (CARES) for women were mailed to 219 patients who underwent APR between 1994 and 2004. Male sexual function was compared to previously published normative data (OLeary MP, Urology 1995). 143 patients responded (response rate 65%; 71% male) of whom 53 (37%) received preoperative, 35 (25%) postoperative XRT, and 55 (38%) were treated with surgery alone. Data: median [range] or mean (SD).
Results
Patients treated without XRT were older compared to both other groups (66 [38-93] years vs. preoperative XRT 57 [25-92] and postoperative XRT 60 [37-88]; p<0.05) while patients who underwent postoperative XRT had the longest follow-up (91 [6-137] months vs. preoperative XRT 47 [1-104] and no XRT 56 [1-134]; p<0.05). Gender distribution was comparable between groups (NS) while XRT patients had higher tumor stages (p<0.05). Urinary function was impaired after preoperative XRT compared to patients treated with surgery alone (p<0.05), while postoperative XRT had no effect. Patients reporting that their “QOL was worse after APR” showed higher AUASI symptom scores (13.2 (8.6) vs. better 7.2 (5.7) and similar 8.8 (6.4); p=0.02) and AUASI satisfaction scale scores (2.8 (1.2) vs. better 1.8 (1.5) and similar 2.2 (1.2); p=0.01), demonstrating correlation of deteriorated urinary function with perception of impaired QOL after APR. Pre- and postoperative XRT increased sexual dysfunction in female patients (p<0.05), while sexual function in male patients was unaffected by pre- and postoperative XRT (NS). However, male APR patients had impaired sexual function on all domains of the BSFI compared to previously published, age-stratified controls (all p<0.05). 33% of patients were sexually inactive at follow-up with higher age, preoperative vs. no XRT, and not living in a relationship being associated with sexual inactivity in multivariable analysis (p<0.05). In sexually inactive patients, younger age, female gender, and preoperative vs. no XRT were associated with the feeling that surgery for rectal cancer caused sexual inactivity (p<0.05). Postoperative vs. no XRT had no such effect (NS).
Conclusions
Although urinary and sexual function might be impaired after APR, effects of XRT appear to be limited. Indication and timing of XRT should be based on oncological aspects rather than on QOL and functional outcome considerations.
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