Definitive external-beam radiation therapy can result in acute cystitis, proctitis, and sometimes enteritis.[1,27,30,31] These are generally reversible but may be chronic and rarely require surgical intervention. Potency, in the short term, is preserved with irradiation in the majority of cases, but may diminish over time. A cross-sectional survey of prostate cancer patients who had been treated in a managed care setting by either radical prostatectomy, radiation, or watchful waiting showed substantial sexual and urinary dysfunction in the radiation therapy group.[28] Morbidity may be reduced with the employment of sophisticated radiation techniques, such as the use of linear accelerators, and careful simulation and treatment planning.[32] Radiation side effects of three-dimensional conformal versus conventional radiation therapy using similar doses (total dose of 60-64 Gy) have been compared in a randomized non-blinded study.[33][Level of evidence: 1iiC] There were no differences in acute morbidity, and late side effects serious enough to require hospitalization were infrequent with both techniques. However, the cumulative incidence of mild or greater proctitis was lower in the conformal arm than in the standard therapy arm (37% versus 56%, p=0.004). Urinary symptoms were similar in the 2 groups, as were local tumor control and overall survival rates at 5 years' follow-up. Radiation therapy can be delivered after an extra-peritoneal lymph node dissection without an increase in complications if careful attention is paid to radiation technique. The treatment field should not include the dissected pelvic nodes. Prior transurethral resection of the prostate (TURP) increases the risk of stricture above that seen with radiation alone, but if radiation is delayed 4 to 6 weeks after the TURP, the risk of stricture can be minimized.[34-36] Although pretreatment TURP to relieve obstructive symptoms has been associated with tumor dissemination, multivariate analysis in pathologically staged cases indicates that this is due to a worse underlying prognosis of the cases that require transurethral resection rather than to the procedure itself.[37]

A population-based survey of Medicare recipients who had received radiation therapy as primary treatment of prostate cancer, similar in design to the survey described above of Medicare patients who underwent radical prostatectomy [24], has been reported, showing substantial differences in post-treatment morbidity profiles between surgery and radiation.[38] Although the men who had undergone radiation were older at the time of initial therapy, they were less likely to report the need for pads or clamps to control urinary wetness (7% versus more than 30%). A larger proportion of patients treated with radiation before surgery reported the ability to have an erection sufficient for intercourse in the month prior to the survey (men <70 years of age, 33% who received radiation versus 11% who underwent surgery alone; men >/=70 years of age, 27% who received radiation versus 12% who underwent surgery alone). However, men receiving radiation were more likely to report problems with bowel function, especially frequent bowel movements (10% versus 3%). Similar to the surgical patient survey, about 24% of radiation patients reported additional subsequent treatment of known or suspected cancer persistence or recurrence within 3 years of primary therapy.

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