Prior studies reported a higher absolute proportion of patients undergoing procedures after radiation who experience toxicities such as urinary incontinence, bladder neck contractures, and urethral strictures compared to those undergoing procedures after radiation therapy.2 The current literature is limited by comparison of small sample sizes, unmatched cohorts, and non-inclusion of novel treatments like prostatic stents and robotic waterjet ablation. To address this gap in the literature, we conducted a propensity-score matched retrospective multi-center cohort study assessing the outcomes of patients with prostate cancer who undergo all BOOP after versus before XRT for prostate cancer using the TriNetX database.4
After propensity-score matching for demographics, comorbidities, and medications received, 411 patients who underwent bladder outlet obstruction procedures after radiation therapy were compared with 411 patients who underwent outlet procedures before radiation therapy. Compared with patients treated before radiation, those undergoing bladder outlet procedures after radiation had significantly higher risks of stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, urinary retention, bladder neck contracture, and urethral stricture formation. Notably, the risk of stress urinary incontinence remained elevated beyond one year, suggesting that these adverse effects are not merely transient postoperative events but may have lasting implications for quality of life. Our findings reinforce an important clinical principle: patients undergoing outlet surgery after radiation experienced substantially higher rates of genitourinary side effects.
As prostate cancer survivorship continues to improve, minimizing treatment-related morbidity becomes increasingly important. When evaluating a patient with localized prostate cancer who is considering radiation therapy, urologists and radiation oncologists should carefully assess baseline lower urinary tract symptoms and the likelihood that surgical intervention will eventually be required. For appropriately selected patients, addressing clinically significant obstruction before radiation may reduce the risk of subsequent urinary complications and improve long-term functional outcomes.
Limitations of the study include possible unknown confounding, limitations from inaccurate diagnostic and procedural coding, and lack of granularity in data regarding symptom severity for symptoms like urinary incontinence. Findings of a retrospective study are not indicative of causation. While minimally invasive surgical treatments (MIST) appeared to be associated with fewer side effects than more invasive prostate procedures after radiation, the sample size was too small to demonstrate a statistically reliable difference. Future studies should further investigate our preliminary findings to determine whether MIST results in fewer post-radiation-induced side effects.
Written by: Renil S. Titus and Ricardo R. Gonzalez
- Department of Urology, Houston Methodist Hospital, Houston, TX
- Porto JG, Blachman-Braun R, Ajami T, et al. Incidental prostate cancer after holmium laser enucleation of the prostate: Critical analysis of independent risk factors and impact on surgical outcomes. BJUI Compass. 2024;5(3):374-381. doi:10.1002/bco2.306
- Titus RS, Bhatia A, Porto JG, et al. A pilot study evaluating the safety and efficacy of En-bloc holmium laser enucleation of the prostate in patients with a history of radiation therapy or high intensity focused ultrasound for management of organ confined prostate cancer with review of the literature. BJUI Compass. 2025;6(7):e70061. doi:10.1002/bco2.70061
- Sanda MG, Dunn RL, Michalski J, et al. Quality of Life and Satisfaction with Outcome among Prostate-Cancer Survivors. N Engl J Med. 2008;358(12):1250-1261. doi:10.1056/NEJMoa074311
- Titus RS, Su J, Riveros C, et al. Comparative analysis of genitourinary toxicity following bladder outlet obstruction procedures in patients before versus after radiotherapy for localized prostate cancer: a retrospective cohort study using the TriNetX database. Prostate Cancer Prostatic Dis. Published online May 28, 2026:1-5. doi:10.1038/s41391-026-01117-4