Marieke van Son

12 CHAPTER 1 neck suspension have failed to show continence improvement compared to standard anastomosis with no reconstruction(40, 41). Depending on tumor location and size, nerve-sparing techniques such as intra-fascial dissection and athermal, traction-free handling of neurovascular bundles may be used in an attempt to preserve erectile func- tion(42). Depending on age and pre-operative function, this may significantly improve post-operative potency(43). Radiotherapy uses high doses of ionizing radiation to treat cancerous tissue, which can be delivered as an external beam (EBRT) or through internal implantation (brachytherapy). Modern techniques to shape the radiation beam and modulate its intensity (IMRT, VMAT) and the integration of imaging modalities into the radiation machine (IGRT) have evolved EBRT from large-field to more conformal treatment, en- abling dose escalation to the tumor while reducing exposure to surrounding healthy organs(44). Common acute toxicities after radiotherapy include dysuria, urinary fre- quency, urinary retention, diarrhea and rectal bleeding, although these usually re- solve over weeks-months(45). Although severe toxicity requiring invasive interven- tion is rare (±2%), long-term side-effects caused by radiation-induced inflammation are more common, such as irritative urinary complaints (±10-20%) and symptoms of proctitis (±15-30%)(46, 47). The occurrence of rectal morbidity is generally lower after brachytherapy compared with EBRT(48). Radiation-induced ED develops slowly over time, increasing from low impotence rates directly after treatment to rates around 50% after 5 years(49, 50). Other sources of energy for treatment are investigated within clinical trial settings. Most investigational data is available from freezing (-40°C, i.e. cryotherapy) and heating (>65°C, i.e. high-intensity focused ultrasound [HIFU]), which are techniques to induce cell death by ischemic necrosis(51, 52). Both ablative treatments have been introduced as a minimally invasive approach which can be performed in an outpatient setting at a lower cost than conventional EBRT or RP(53). Comparative outcome data is sparse, with only two randomized controlled trials (RCT) comparing cryotherapy to EBRT. At a median follow-up nearing 9 years, cryotherapy seems most suited for less bulky prostate cancer (<T2c) although no clear difference was found in overall or disease-spe- cific survival as compared to EBRT(54, 55). Short-term procedural complications of cryotherapy are rare, such as acute urinary retention (±4%), urethral stricture (±1%), recto-urethral fistula formation (0-6%) and rectal pain (±3%). One year post-cryother- apy morbidity seems limited with ±20% ED and ±3% urinary incontinence. No RCT’s are available comparing HIFU to standard treatment. From what is described in case series, acute side-effects are more common, including dysuria (±20%), urinary retention (±10%), urethral stricture (±8%), rectal pain (±11%) and recto-urethral fistula (0-5%). Major long-term effects include ±23% ED and ±10% urinary incontinence(53). Treatment guidelines vary by risk group (Figure 4), reflecting the differences in the critical trade-off between cancer control and potential harm from treatment.