Orchiepididymitis as a rare complication of TURP performed four weeks after high-dose-rate brachytherapy for prostate cancer

Abstract

The aim of this paper was to present a rare complication of orchiepididymitis in a patient treated with brachytherapy (BT) for prostate cancer, who underwent trans-ureteral resection of the prostate (TURP) four weeks after BT. A 73-year-old patient with prostate cancer (intermediate-risk group) was eligible for high-dose-rate (HDR) BT combined with androgen deprivation therapy (ADT) for 6 months (leuprorelin). Due to increased symptoms, such as urinary retention after BT, the patient required catheterization. Additionally, bacterial inflammation in the lower urinary tract and prostate was present. Due to prolonged micturition disorders, TURP was performed, leading to chronic orchiepididymitis four months after completion of BT and three months after catheter removal following TURP. Due to long-term inflammation, which was resistant to treatment, the left testicle with left epididymis was removed. Unfortunately, inflammatory symptoms occurred post-operatively in the bed and the left groin. Since these symptoms of varying severity continued, anti-inflammatory drugs and analgesics were introduced. TURP performed too quickly after HDR-BT might cause severe complications. Extreme caution regarding TURP should be exercised in patients undergoing BT. Conservative and pharmacological treatment must be introduced in the occurrence of urinary disorders after BT, and any intervention (TURP) should be performed at least 3-6 months after BT. This is especially crucial because of the development of radiation effect over time.

Keywords: HDR-BT; MR; TURP; US examination; brachytherapy; lower urinary tract symptoms; orchiepididymitis; prostate cancer; suprapubic cystostomy; urinary retention.

Fig. 1

Prostate MRI before prostate biopsy and brachytherapy. A) Sagittal T2-weighted image, cancer (yellow circle) in the peripheral zone, enlargement of the transitional zone due to benign prostate hyperplasia. B) Axial T2-weighted image, cancer (yellow circle) in the peripheral zone behind and to the left of the urethra. C) Coronal T2-weighted image, cancer (yellow circle) in the peripheral zone. D) Axial image on ADC map, cancer in the peripheral zone behind and to the left of the urethra (yellow circle); low IS on ADC map, ADC value: –0.55 × 10-3 mm2/s. E) Axial image, DWI bmax 2000 s/mm2; cancer in the peripheral zone behind and to the left of the urethra (yellow circle), high IS on DWI. F, G) Focal enhancement on the peripheral zone in cancer focus (yellow circle). H, I) Normal testes and left epididymis before treatment

Fig. 2

MRI at 10 months after brachytherapy. Inflammatory infiltration of the left epididymis (red arrow) with abscess formation involving the left testis (yellow arrow). A, E) T2-weighted images. B, F) T2-weighted images with fat saturation (FS). C, G) T1-weighted images. D, H) T1-weighted FS images with contrast enhancement

Fig. 3

MRI at 22 months after brachytherapy. Inflammatory infiltration of the left epididymis (red arrow) involving the left testis (yellow arrow). A-D) T2-weighted images. E-H) T2-weighted images with fat saturation (FS). I-L) T1-weighted FS images with contrast enhancement

Fig. 4

Ultrasound examination at 23 months after brachytherapy. A, B) Inflammatory infiltration of the left epididymis involving the left testis (yellow arrow), with inflammatory infiltration of the skin and subcutaneous tissue (red arrow). C) Inflammatory infiltration with pathological increase of flow in Color Doppler

Fig. 5

MRI at 5 months after left orchiectomy, 30 months after brachytherapy. Inflammatory infiltration with small abscesses and post-operative lesions in the bed of the left testis and in the left groin (red arrow). A) Axial T2-weighted image. B) Axial T2-weighted image with fat saturation (FS). C) Axial T1-weighted FS image with contrast enhancement. D) Axial DWI bmax 2000 s/mm2 image. E) Axial image on ADC map. F) Coronal T2-weighted image

Fig. 6

Prostate MRI at 8 months after left orchiectomy, 33 months after brachytherapy. Post-operative defect in the transition zone with abnormal position of the urethra and the promontory area. Asymmetry of the seminal vesicle orifice on the left (yellow arrow). A-C) Axial T2-weighted images. D-E) Coronal T2-weighted images. F) Sagittal T2-weighted image