Controversies in Post-Prostatectomy Incontinence Management: Role of Urodynamics Testing and Sequence of Continence Surgery with Salvage Radiation Therapy

This paper evaluates the current evidence on the role of urodynamics in prostatectomy incontinence (PPI) and should male sling (MS) or artificial urinary sphincter (AUS) surgery be performed before or after patients receiving radiation therapy in terms of continence outcomes.

The prevalence of PPI is more common in patients undergoing radical prostatectomy than benign prostatic surgery, and the presence of postoperatively de novo overactive bladder and urge incontinence is not common even without the addition of radiation therapy. Hence, the question arises whether patients presenting with PPI should undergo formal urodynamics testing to exclude detrusor overactivity prior to continence surgery. There is a consensus that the spontaneous recovery of continence is less likely in the setting of salvage radiation therapy. The decision to undertake surgery is likely dictated by patient preference and the urgency for salvage radiation therapy. While the exact choice of MS or AUS, and the sequence of continence surgery in relation to salvage radiation therapy are debatable, irradiated patients are considered a high-risk group with substantially higher risks of postoperative complications.

Urodynamics should be organized in non-classic SUI or mixed incontinence symptoms with PPI and those who had radiation therapy since it can provide useful information in counselling patients regarding continence outcomes and postoperative expectations. It is important to place greater emphasis on preoperative evaluation and surgical vigilance in irradiated patients with PPI.