**3.2.2 Toxicity of high dose rate brachytherapy**

Mild and transient acute urinary symptoms (dysuria and hematuria of grade G1) followed HDR brachytherapy in about 50% of patients in the first week or two, and persist for up to 6 months in less than 35% of treated patients, while grade G2 symptoms occurred in about 11 % of patients in the first weeks after treatment and after 6 months they completely disappeared. Pronounced symptoms of grade G3 (urethral stricture at the level of bladder base) are very rare (less than 2%), and they require a retention of urinary catheter, and usually occur immediately after irradiation, and disappear within ten days. Acute symptoms of grade G1 rectum (proctitis, tenesma and bleeding) are rare and mainly are result of edema and hematoma, and occur in less than 25% of patients in the first weeks and decrease to about 8% in the 6-month after conducted therapy. Acute complications of grade G3 were not observed.

All listed acute symptoms may be connected to radiation and trauma during application procedure, although problems have not been noted during the application itself.

The frequency and severity of late complications after HDR brachytherapy is similar to the permanent implant brachytherapy (LDR), except that complications associated with the migration of radiation sources do not occur.

When HDR brachytherapy (22-24 Gy/5-6 fr.) is applied in combination with transcutaneous radiotherapy (EBRT to 40Gy), the results of treatment (five-year survival NED/biochemical/and overall survival) of 63% in patients with high risk are comparable and slightly better than with the application of brachytherapy (LDR and HDR) as a monotherapy. (Deamens et al., 2009) In the same paper, the authors conclude that no benefit was noted when applying deprivate androgen therapy in relation to combined radiotherapy.

Acute and late effects on the bladder and rectum are more pronounced in cases of combined radiotherapy, which can be expected.
