LAUSR

Background Despite detailed instruction for full bladder, patients are unable to maintain consistent bladder filling during a 5-week pelvic radiation therapy (RT) course. We investigated the best bladder volume estimation procedure for verifying consistent bladder volume. Methods We reviewed 462 patients who underwent pelvic RT. Biofeedback using a bladder scanner was conducted before simulation and during treatment. Exact bladder volume was calculated by bladder inner wall contour based on CT images (V ctsim ). Bladder volume was estimated either by bladder scanner (V scan ) or anatomical features from the presacral promontory to the bladder base and dome in the sagittal plane of CT (V ratio ). The feasibility of V ratio was validated using daily megavoltage or kV cone-beam CT before treatment. Results Mean V ctsim was 335.6 ± 147.5 cc. Despite a positive correlation between V ctsim and V scan ( R 2  = 0.278) and between V ctsim and V ratio ( R 2  = 0.424), V ratio yielded more consistent results than V scan , with a mean percentage error of 26.3 (SD 19.6, p  < 0.001). The correlation between V ratio and V ctsim was stronger than that between V scan and V ctsim (Z-score: − 7.782, p  < 0.001). An accuracy of V ratio was consistent in megavoltage or kV cone-beam CT during treatment. In a representative case, we can dichotomize for clinical scenarios with or without bowel displacement, using a ratio of 0.8 resulting in significant changes in bowel volume exposed to low radiation doses. Conclusions Bladder volume estimation using personalized anatomical features based on pre-treatment verification CT images was useful and more accurate than physician-dependent bladder scanners. Trial registration Retrospectively registered.