Prostate cancer with kidney failure: is surgery, focal therapy or radiation the right choice?

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A patient guide by Dr Jo Schoeman

A diagnosis of prostate cancer is unsettling. Having chronic kidney disease or needing dialysis can make treatment decisions feel even harder. The reassuring point is that kidney failure does not automatically rule out treatment. The best choice depends on the cancer, the degree of kidney impairment, other medical conditions and, crucially, whether a kidney transplant is planned.

What does Gleason 3+4 mean?

Gleason 3+4=7 is Grade Group 2 prostate cancer. Most of the sampled tumour has pattern 3, with a smaller component of pattern 4. It is generally less concerning than Gleason 4+3=7, but “3+4” alone cannot tell us whether immediate treatment is needed.

I would review the PSA and PSA density, examination, MRI findings, number and length of positive biopsy cores, percentage of pattern 4, any cribriform or intraductal cancer, and whether disease is confined to the prostate. Kidney function, dialysis schedule, life expectancy and transplant eligibility are considered alongside these findings. Some men have favourable intermediate-risk cancer; others have features that make definitive treatment more appropriate. Staging scans are selected according to overall risk rather than biopsy grade alone. [1,2]

Could active surveillance be reasonable?

Yes, for selected men with small-volume, favourable Grade Group 2 cancer. Surveillance means scheduled PSA tests, clinical review, MRI where useful and repeat biopsy when indicated. It keeps treatment available if the cancer changes. It is a particularly meaningful option when another serious illness makes the harms of immediate treatment more likely to outweigh its benefit. It does, however, require a patient who can attend follow-up and accepts a small increased risk of progression compared with immediate treatment. [1,2]

If kidney disease or other illnesses substantially limit life expectancy, watchful waiting may be more appropriate: care focuses on symptoms rather than routine testing intended to trigger curative treatment. This is a separate decision from active surveillance. [1]

Can radical prostatectomy or robotic surgery be performed?

Often, yes. Chronic kidney disease and dialysis are not automatic contraindications to radical prostatectomy. Robotic assisted surgery may offer less blood loss and a shorter hospital stay than open surgery in selected patients, but it still involves general anaesthesia, abdominal insufflation and a head-down operating position. Advanced kidney disease increases the importance of planning for bleeding, infection, fluid and electrolyte balance, medication dosing and postoperative kidney injury. Population studies find higher complication rates in patients with chronic kidney disease, particularly advanced disease; individual risk varies considerably. [3,4]

Before an operation I would coordinate with the nephrologist, anaesthetist and, where relevant, dialysis team. We would assess cardiovascular health, haemoglobin, potassium, anticoagulants, residual kidney function and the timing of dialysis. Surgery also carries the usual risks of urinary leakage or incontinence, erectile dysfunction, infertility, blood clots and possible need for further cancer treatment. Whether a robotic approach is feasible depends on the patient and the surgical team; it is not automatically a safer choice for every person with kidney failure. [1,3,4]

Is focal therapy a better option?

Not simply because the kidneys are failing. Focal therapy treats the visible cancer-bearing portion of the prostate, using a technique such as focused ultrasound, cryotherapy or another ablative method. It may appeal to men hoping to reduce urinary or sexual side effects, but the cancer can be present elsewhere in the gland, and longer-term cancer control is less certain than for established whole-gland treatments. Further MRI, biopsies and sometimes repeat treatment are necessary.

The AUA/ASTRO guideline notes a lack of high-quality comparisons with surgery, radiation and surveillance. European guidance restricts focal treatment to settings with careful prospective follow-up, such as a trial or registry. Kidney disease alone does not establish that focal treatment is preferable. In a suitable patient it can be discussed with a specialist who explains uncertainty, access, costs and a clear follow-up plan. [1,2]

Is radiotherapy an option?

Yes. External beam radiotherapy avoids major surgery and usually does not expose the kidneys directly when treating a prostate confined to the pelvis. Options include moderately shortened courses and, for selected men, more condensed schedules or brachytherapy. The radiation oncologist will tailor treatment to the cancer and urinary function. Depending on whether the disease is favourable or unfavourable intermediate risk, a course of androgen deprivation therapy (ADT) may also be advised; ADT has its own effects on energy, muscle, bone and metabolic health. [1,2]

Radiotherapy may cause temporary urinary frequency, burning or bowel upset; longer-term urinary, bowel or erectile effects are also possible. Existing urinary obstruction and kidney transplant anatomy can change planning. In a transplant recipient, the graft and ureter may sit in the pelvis, so radiation dose constraints require particular attention. Dialysis, by itself, does not make prostate radiation impossible. [1,2]

What if a kidney transplant is planned?

This is a central part of the discussion. A transplant team may need to know whether the cancer is under surveillance or has been treated, its estimated risk of progression and the proposed follow-up. The presence of prostate cancer does not automatically mean that transplantation must wait for a fixed number of years; transplant eligibility is individual and should be discussed directly with the transplant team. A transplanted kidney in the pelvis also affects the planning of later pelvic surgery or radiotherapy. [5]

How do we decide?

Option When it may fit Main trade-off
Active surveillance Low-volume, favourable Grade Group 2 disease Regular testing and a possibility of later treatment
Robotic radical prostatectomy Fit patient seeking definitive local treatment Anaesthetic and surgical risks, with continence and erectile side effects
Radiotherapy Patient seeking definitive treatment without prostate removal Urinary, bowel and sexual effects; ADT may be needed
Focal therapy Carefully selected patient after discussion of uncertainty Less established long-term cancer control and ongoing biopsies
Watchful waiting Limited life expectancy or major competing health risks Treats symptoms if they arise rather than aiming for cure

There is no universal winner between robotic surgery and radiation for Gleason 3+4 cancer with kidney failure. A multidisciplinary discussion involving urology, radiation oncology, nephrology and the transplant team, if applicable, helps align cancer control with kidney health and the patient’s priorities.

This article offers general information and cannot determine treatment for an individual patient. Decisions require review of the pathology, imaging, kidney function and overall health.

References

  1. European Association of Urology. EAU Guidelines on Prostate Cancer: Treatment. Accessed September 2026.
  2. American Urological Association and American Society for Radiation Oncology. Clinically Localized Prostate Cancer Guideline. 2022.
  3. Post-surgical outcomes of patients with chronic kidney disease and end stage renal disease undergoing radical prostatectomy: 10-year results from the US National Inpatient Sample. 2019.
  4. The Effect of Chronic Kidney Disease on Adverse In-Hospital Outcomes at Radical Prostatectomy. 2025.
  5. Kidney Disease: Improving Global Outcomes. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. 2020.

Urethral bulking for stress urinary incontinence: a first procedure or an option after a sling?

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Leaking urine when you cough, laugh, exercise or lift something is called stress urinary incontinence (SUI). It differs from urgency incontinence, when a sudden need to pass urine leads to leakage. Some women have both. Identifying which symptom is most troublesome matters because an injection aimed at SUI will not reliably treat urgency.

Urethral bulking involves placing small deposits of material into the wall of the urethra, usually through a fine instrument passed into the urethra. The deposits help the urethra close when pressure rises. You may hear this described as periurethral bulking, although many contemporary injections are delivered through the urethra into its surrounding wall. This is generally a day procedure under local anaesthesia or sedation/general anaesthesia, depending on the circumstances. It does not place a sling or mesh tape.

Could bulking be my first procedure?

Yes. After a trial of pelvic floor muscle training and discussion of other conservative measures, bulking can be chosen as a first procedure for appropriately assessed SUI. It may appeal to someone seeking a shorter procedure and recovery, or wishing to avoid a sling. It is also an option when a larger operation or anaesthetic carries additional risk. It is not usually the first treatment before conservative care. USANZ’s 2026 position statement lists bulking alongside autologous fascial slings, colposuspension and synthetic midurethral slings among the standard options that should be discussed. UGSA’s patient information stresses its lower success and frequent need for repeat treatment. [1–3]

Bulking, synthetic midurethral sling surgery, a sling made from the patient’s own fascia, and colposuspension have different benefits and risks. A donated-tissue (allograft) sling is distinct from a sling made from your own tissue (autograft) and from a synthetic mesh sling; the strength and duration of evidence for each are different. No single procedure is best for every woman. [1,4]

How effective and durable is it?

The realistic aim is often less leakage, rather than guaranteed dryness. Success figures change substantially depending on whether researchers count complete dryness, improvement, satisfaction, or avoidance of further treatment. UGSA’s patient leaflet quotes about 40–50% cure or improvement and reports that approximately 30% need a further injection within two years. These are broad counselling figures, not a prediction for an individual. [2]

Some women remain improved for years, but repeat injections or another operation may be needed. In a randomised comparison of polyacrylamide hydrogel injection and synthetic tension-free vaginal tape for primary SUI, the tape achieved better objective continence at one year (negative cough test 95.0% versus 66.4%). The five-year follow-up did not establish that injection was non-inferior to tape. The EAU similarly advises that bulking is generally less effective than slings or colposuspension for cure, and that repeat injection is likely. These findings do not mean everyone should have a tape: the value of a less invasive procedure and the acceptability of a possible repeat treatment are personal considerations. [4–6]

What if I still leak after a sling?

Bulking can be considered for persistent leakage soon after a sling or recurrent leakage after an initial period of improvement. It can sometimes reduce leakage without placing another sling. A 2022 systematic review of 11 studies after synthetic midurethral sling failure reported a pooled 75% cure-or-improvement rate, but also pooled failure and further-operation rates of 32% and 25%. The studies differed considerably in their patients, products, follow-up and definitions of success; the 75% figure should not be presented as a personal chance of cure. An American Urogynecologic Society clinical practice statement also recognises bulking as an option after a sling. [7,8]

After an allograft sling, the same clinical possibility exists, but the published post-sling bulking evidence is mainly about synthetic midurethral slings. We should not simply transfer those success figures to donated-tissue slings. The precise graft, previous surgery and examination findings should guide an individual discussion.

An injection should not be used to mask a sling complication. Before offering more treatment, I would review the original operation, check urine and bladder emptying, examine for prolapse, scarring and vaginal exposure, and assess whether leakage occurs with coughing or with urgency. Cystoscopy, a bladder diary, pad testing or urodynamics may be appropriate, especially after previous surgery, mixed symptoms, pain, blood in the urine or difficulty emptying. A tape or graft causing obstruction, exposure, erosion, infection or pain may require its own assessment and treatment. [1,3,7]

Is it safe? What are the side effects?

Most reported problems are short lived, but no injection is risk free. Possible effects include:

  • burning when passing urine and a little blood in the urine;
  • urinary tract infection;
  • temporary difficulty emptying the bladder, occasionally requiring short-term catheterisation;
  • new or persisting urgency symptoms; and
  • incomplete benefit, recurrence or the need for another injection or operation.

Less commonly, there may be persistent pain, a collection or infection at the injection site, or a reaction or complication related to the particular material. Risks also depend on anaesthesia, previous surgery and the chosen product. Emptying should be checked before discharge. Seek prompt assessment if you cannot pass urine, develop fever, worsening pain or heavy bleeding. [2,4,8]

Choosing a treatment

The first step is to confirm the type and severity of leakage and clarify your goals: complete dryness, meaningful improvement, shorter recovery, avoiding mesh, or avoiding the likelihood of repeat treatment. Pelvic floor therapy remains an initial option. When a procedure is appropriate, we can compare bulking with sling and colposuspension procedures using your examination findings, health history and preferences. If you have already had a sling, the reason for the continuing leakage deserves a fresh assessment before choosing another procedure.

This page is general education, not a recommendation for a particular product or a promise of a result. Treatment, including its material, risks, costs and alternatives, should be discussed during an individual consultation.

References

  1. Urological Society of Australia and New Zealand (USANZ). Surgical Treatment of Stress Urinary Incontinence: Position Statement Pol 054, version 2.0. Approved 9 May 2026.
  2. Urogynaecological Society of Australasia (UGSA). Urethral Bulking: Patient Information.
  3. UGSA. Stress Urinary Incontinence: Patient Resources.
  4. European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms: Disease Management, section 4.2.4.c.2.c.
  5. Itkonen Freitas A-M, et al. Tension-free vaginal tape surgery versus polyacrylamide hydrogel injection for primary stress urinary incontinence: a randomised clinical trial. Journal of Urology. 2020.
  6. Itkonen Freitas A-M, et al. Tension-free vaginal tape versus polyacrylamide hydrogel injection for stress urinary incontinence: five-year follow-up. NEJM Evidence. 2025.
  7. Braga A, et al. Urethral bulking agents for the treatment of recurrent stress urinary incontinence: a systematic review and meta-analysis. Maturitas. 2022. doi:10.1016/j.maturitas.2022.05.007.
  8. American Urogynecologic Society. Urethral Bulking: Clinical Practice Statement. Urogynecology. 2024. doi:10.1097/SPV.0000000000001548.

Testicular rupture: causes, warning signs, diagnosis and treatment

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Testicular rupture is a surgical emergency. It occurs when trauma tears the tough outer covering of the testis (the tunica albuginea), allowing testicular tissue to protrude through the defect. Prompt assessment offers the best opportunity to control bleeding, relieve pain and preserve viable testicular tissue.

Seek urgent medical care: After an injury, go promptly to the nearest emergency department if there is severe or increasing scrotal pain, marked swelling or bruising, nausea or vomiting, a testis that feels abnormal or cannot be clearly felt, an open wound, or blood at the urinary opening or in the urine. Do not delay assessment while waiting to see whether the swelling settles.

What causes a testicular rupture?

Most ruptures follow a forceful, direct blow that compresses the testis against the pubic bone. Causes include:

  • contact sport, particularly without an appropriate protective cup;
  • bicycle or motorcycle accidents and straddle injuries;
  • falls, motor-vehicle trauma, workplace injuries or assault;
  • a kick, ball or other high-impact object striking the scrotum; and
  • penetrating trauma, such as a stab, gunshot, machinery injury or animal bite.

A major blunt injury can also cause a scrotal haematoma, haematocele (blood around the testis), testicular contusion, torsion, fracture without tunical rupture, or injury to the epididymis or spermatic cord. These conditions can look similar, and more than one injury may be present.

How does it present?

Typical features include immediate severe pain followed by rapidly developing swelling, tenderness and bruising. Nausea, vomiting or faintness may occur. The normal outline of the testis may be difficult to feel because of pain and swelling. An open injury, scrotal skin loss or bleeding may be present after penetrating or high-energy trauma.

Symptoms alone cannot reliably distinguish rupture from torsion or other serious injury. Testicular torsion may occur with or without trauma and is also time-critical. A seemingly modest external bruise does not exclude a significant internal injury.

Assessment and investigation

Assessment begins with the circumstances and timing of the injury, examination of both testes and the scrotum, and checking for injury to the penis, urethra, pelvis and abdomen where relevant. Blood at the urethral opening, difficulty passing urine or visible blood in the urine requires assessment for associated urinary-tract injury.

Ultrasound with Doppler

High-resolution scrotal ultrasound with colour Doppler is the preferred first-line imaging test for blunt testicular trauma. Findings that may indicate rupture include:

  • loss of the smooth testicular contour;
  • disruption of the tunica albuginea;
  • heterogeneous testicular tissue;
  • protrusion of tissue through a tunical defect;
  • reduced or absent blood flow; and
  • a surrounding haematocele.

Ultrasound is very useful but is not infallible. Pain, extensive swelling, haematoma and operator or equipment factors can make interpretation difficult. The 2026 European Association of Urology (EAU) guideline strongly recommends ultrasound for testicular trauma and surgical exploration for confirmed rupture and for inconclusive ultrasound when rupture remains a concern. Imaging should not cause an avoidable delay when the clinical findings clearly warrant surgery.

CT is useful for associated abdominal or pelvic trauma but is not the usual test for deciding whether the testis has ruptured. MRI is occasionally considered when ultrasound is equivocal and immediate exploration is not otherwise indicated, but it should not delay necessary surgery.

Treatment

Immediate care

In hospital, initial treatment may include appropriate pain relief, fasting in preparation for possible anaesthesia, scrotal support and management of other injuries. Open or contaminated wounds require wound care; tetanus status and antimicrobial treatment are considered according to the mechanism, contamination and local protocols.

Surgical exploration and repair

Confirmed or strongly suspected rupture is generally treated by urgent scrotal exploration. During surgery, the surgeon will usually:

  1. evacuate blood clot and inspect the testis and surrounding structures;
  2. control bleeding;
  3. remove only tissue that is clearly non-viable;
  4. preserve as much healthy, perfused testicular tissue as possible; and
  5. close the tunica albuginea, sometimes using local tissue coverage when primary closure would place the remaining testis under excessive tension.

Associated injuries to the epididymis or spermatic cord are addressed where possible. A drain may occasionally be used. After surgery, patients commonly require scrotal support, analgesia, wound care and temporary restriction of sport, heavy lifting and sexual activity. The exact plan depends on the injury and operation.

Older clinical series reported testicular salvage rates around 80–90% when rupture was recognised and repaired promptly. These figures describe groups of patients and cannot predict an individual result. The chance of salvage depends on the energy and type of trauma, the amount of tissue destruction, blood supply, contamination, associated injuries and time to treatment.

Is non-operative treatment ever suitable?

Minor trauma with an intact tunica, preserved blood flow and a small, stable haematoma may sometimes be managed with observation, analgesia, ice used safely, scrotal support and arranged review. This is not the usual management for a confirmed rupture. Increasing pain, swelling, fever or other deterioration requires urgent reassessment.

When is orchidectomy necessary?

Orchidectomy means removal of a testis. It is not the preferred treatment when viable tissue can be repaired. It may nevertheless be necessary when the testis is completely shattered, devascularised or infarcted; the spermatic cord is irreparably damaged or avulsed; bleeding cannot otherwise be controlled; contamination and tissue destruction are extreme; or no meaningful viable tissue remains.

The decision is usually made during exploration after blood supply and tissue viability have been assessed. Surgeons aim to conserve viable testicular tissue, but retaining a completely non-viable testis can expose the patient to infection, persistent pain and further surgery. Severe penetrating injuries and delayed treatment are more likely to require orchidectomy than a limited rupture treated early.

If removal is required, a testicular prosthesis can be discussed. It is cosmetic and does not make sperm or testosterone. Placement may be performed at the same operation or later, depending on contamination, swelling, patient preference and clinical circumstances.

Effects on fertility and testosterone

The effect on fertility varies considerably.

  • Unilateral injury: A healthy opposite testis will often produce enough testosterone and sperm for normal sexual development, erections and natural conception. However, normal fertility cannot be guaranteed. Trauma itself, loss of testicular volume, later atrophy and unilateral orchidectomy can reduce sperm reserve.
  • Testicular repair: Preserving viable tissue is generally preferred and may better preserve sperm-producing and hormonal function. Small human follow-up studies suggest that semen abnormalities can occur after trauma even when testosterone remains normal; the evidence is limited by small patient numbers.
  • Bilateral injury or a solitary testis: The risk to fertility and testosterone production is much greater. Loss of both testes causes permanent infertility and requires long-term testosterone replacement. Preservation of even a portion of viable tissue may therefore be especially important.

For severe bilateral injury, injury to a solitary testis, pre-existing subfertility, or concern about future family planning, early discussion with a urologist and fertility specialist is appropriate. Semen analysis, reproductive hormone testing and sperm cryopreservation may be considered when feasible; emergency surgery should not be dangerously delayed to obtain a sample. Follow-up may include examination, ultrasound when indicated, testosterone, LH and FSH testing, and semen analysis after recovery if fertility is a concern.

Possible complications

Even after appropriate treatment, complications can include:

  • infection, wound problems or recurrent haematoma;
  • testicular atrophy or loss of blood supply;
  • persistent scrotal discomfort or chronic pain;
  • impaired sperm production or subfertility;
  • reduced testosterone production, particularly after bilateral injury;
  • the need for later surgery or orchidectomy; and
  • psychological distress or concern about body image and fertility.

Increasing pain or swelling, fever, wound discharge, skin discolouration, difficulty passing urine or feeling generally unwell after discharge warrants urgent medical review.

The practical message

Following significant scrotal trauma, early assessment matters. Ultrasound with Doppler is the main imaging investigation, but a reassuring-looking exterior, or an uncertain scan, does not safely exclude rupture. Timely exploration and repair provide the best opportunity to save viable testicular tissue. Orchidectomy is reserved for a testis that cannot be safely or meaningfully salvaged.

Important information

This article provides general health information and does not replace an examination, diagnosis, individual medical advice or informed consent. Treatment and outcomes vary according to the mechanism, severity, timing, associated injuries, health history and operative findings. If testicular rupture or torsion is suspected, seek urgent assessment at an emergency department.

References

  1. European Association of Urology. EAU Guidelines on Urological Trauma: Urogenital Trauma Guidelines (2026). Uroweb guideline.
  2. Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. Journal of Urology. 2014;192:327–335. Full text via PubMed Central. Updated guideline information: American Urological Association.
  3. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. Journal of Urology. 2021;205(1):30–35. PubMed.
  4. Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. Journal of Urology. 2006;175(1):175–178. PubMed.
  5. Cass AS, Luxenberg M. Testicular injuries. Urology. 1991;37(6):528–530. PubMed.
  6. Lin WW, Kim ED, Quesada ET, Lipshultz LI, Coburn M. Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters. Journal of Urology. 1998;159(3):841–843. PubMed.
  7. Kukadia AN, Ercole CJ, Gleich P, Hensleigh H, Pryor JL. Testicular trauma: potential impact on reproductive function. Journal of Urology. 1996;156(5):1643–1646. PubMed.
  8. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. Journal of Ultrasound in Medicine. 2010;29(1):11–21. PubMed.
  9. Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service and acceptable evidence in health advertising. Ahpra Advertising Hub.
  10. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods (updated 18 June 2026). TGA guidance.

 

Penile Fracture: Presentation, Investigation, Treatment and Long-Term Outlook

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Penile fracture is a urological emergency. Despite its name, no bone is broken. The injury is a tear in the tunica albuginea, the tough sleeve surrounding one or both erectile cylinders (corpora cavernosa) while the penis is erect. Bleeding then occurs within and around the erectile tissues.

If you hear or feel a crack or pop during intercourse or other bending of an erect penis, followed by pain, loss of the erection, swelling or bruising, stop sexual activity and attend the nearest emergency department immediately. Do not wait to see whether it settles, and do not eat or drink until assessed in case an anaesthetic is required.

This article provides general education. It cannot diagnose an injury, replace examination, or provide individual medical advice.

How does a penile fracture happen?

During an erection, the tunica albuginea becomes much thinner and is vulnerable to sudden buckling. The most frequent mechanism is an erect penis slipping out during intercourse and striking the partner’s pubic bone or perineum. It can also occur during masturbation, intentional forceful bending, rolling onto an erect penis, or less commonly through other trauma.

Penile fracture can happen in any sexual position. It is an accident rather than evidence of wrongdoing, and embarrassment should never delay treatment.

The urethra, the tube carrying urine through the penis, may be injured at the same time. The 2026 European Association of Urology (EAU) guideline reports associated corpus spongiosum or urethral injury in approximately 10–22% of cases; rates vary among populations and mechanisms of injury.[1]

Typical presentation

The classic sequence is:

  • a sudden crack, snap or popping sensation;
  • immediate pain;
  • rapid loss of the erection (detumescence);
  • quickly developing swelling and bruising;
  • bending or deformity of the penis, often away from the injured side; and
  • sometimes a palpable defect in the tunica.

Bruising may spread into the scrotum, perineum or lower abdominal wall. The dramatic “aubergine” appearance described in medical literature is not present in every case.

Warning signs of urethral injury

Tell the treating team immediately if there is:

  • blood at the urinary opening;
  • blood in the urine;
  • pain or difficulty passing urine;
  • inability to pass urine; or
  • a weak or interrupted urinary stream after the injury.

The absence of these findings does not completely exclude urethral injury. Clinical assessment remains important.

Conditions that can look similar

Not every swollen or bruised penis after intercourse has a tunical tear. Rupture of a superficial vein or artery, injury to the suspensory ligament, or bleeding beneath the skin can produce a “false penile fracture.” Slow rather than immediate loss of erection and absence of the characteristic crack may make a true fracture less likely, but no single feature is conclusive.

Because missing a fracture can have lasting consequences, significant swelling, pain or deformity after trauma to an erect penis requires urgent medical assessment.

How is it investigated?

History and examination

When the history and examination are classic, penile fracture is primarily a clinical diagnosis. Testing should not unnecessarily delay repair. The clinician will assess the penis, scrotum and perineum and ask specifically about the mechanism, the speed of detumescence, urination and visible blood. A urine test is generally performed.

Ultrasound

Ultrasound can help locate a tear and haematoma, particularly when the diagnosis is uncertain. It is quick and widely available, but its accuracy depends on the operator, the size and position of the tear, and the amount of swelling. A negative or inconclusive ultrasound does not necessarily exclude fracture when the clinical findings are convincing.

MRI

MRI gives excellent soft-tissue detail and is generally more accurate than ultrasound for detecting a tunical tear. It may be useful in equivocal cases, but availability, cost and delay can limit its emergency use. It is not routinely required when the diagnosis is already clear.[1]

Assessment of the urethra

If urethral injury is suspected, evaluation may include retrograde urethrography (contrast imaging of the urethra) or flexible cystoscopy. Visible haematuria, blood at the meatus, difficulty voiding and bilateral corporal injury increase concern. The EAU and American Urological Association (AUA) both recommend evaluating for associated urethral injury when indicated.[1,2]

CT is not the preferred test for an isolated penile fracture, although it may be obtained when wider pelvic or abdominal trauma is suspected.

Recommended management

Prompt surgical repair

Current EAU and AUA guidance recommends prompt surgical exploration and repair for an acute penile fracture.[1,2] The operation is usually performed under general or regional anaesthesia and involves:

  1. exposing the injured erectile tissue through a circumferential degloving incision or a targeted incision over the tear;
  2. evacuating the clot and controlling bleeding;
  3. identifying and closing the tunica albuginea tear with sutures; and
  4. inspecting and repairing the urethra if it is injured.

A urinary catheter may be used, especially when the urethra has been assessed or repaired. The exact incision, catheter duration, hospital stay and follow-up depend on the injury and the surgeon’s findings.

The EAU guideline advises repair within 24 hours of presentation when feasible, but late presentation is not a reason to withhold assessment or repair.[1] A person presenting after a delay should still seek urgent urological review.

Why is conservative treatment generally avoided?

Ice, compression, pain relief, erection-suppressing medication and observation were historically used. Conservative treatment may occasionally be appropriate when imaging and specialist assessment confirm that the tunica is intact, but it is not the standard treatment for a confirmed fracture.

A meta-analysis of 58 studies involving 3,213 patients found significantly fewer overall complications and less erectile dysfunction, curvature and painful erections with surgery than with conservative management.[3] Non-operative treatment of a true fracture carries greater risks of persistent haematoma, infection or abscess, missed urethral injury, fibrosis, penile curvature and erectile dysfunction.[1,3]

Recovery after repair

Patients should follow their treating surgeon’s instructions, which may include:

  • wound and catheter care;
  • simple analgesia and other prescribed medicines;
  • avoiding strenuous activity until reviewed;
  • avoiding intercourse and masturbation, commonly for about six weeks or until healing is confirmed; and
  • follow-up to assess erections, curvature, pain and urinary function.

Night-time or spontaneous erections during healing may be uncomfortable. Medication is sometimes used selectively, but there is no universal post-operative drug regimen. Do not start or stop prescription medicines without advice.

Seek urgent review after treatment for fever, increasing redness or swelling, wound discharge, worsening pain, inability to urinate, heavy bleeding, or a catheter that stops draining.

Possible complications

Most patients do well after prompt repair, but no treatment can guarantee a complication-free outcome. Possible early or late problems include:

  • wound infection, bleeding or haematoma;
  • altered penile sensation, palpable stitches, scar or nodules;
  • painful erections;
  • penile curvature, indentation or shortening;
  • erectile dysfunction;
  • urethral narrowing (stricture), urinary spraying or reduced flow;
  • urethrocutaneous fistula after a significant urethral injury or repair;
  • need for further investigation or surgery; and
  • anxiety, avoidance of intimacy or relationship distress.

The EAU guideline summarises reported post-surgical rates of plaques or nodules, curvature and erectile dysfunction as approximately 13.9%, 2.8% and 1.9%, respectively, while noting that complications overall have been reported in up to 20% of cases.[1] These pooled figures are not a personalised prediction: published studies differ in injury severity, definitions, follow-up and measurement. Risk is higher with extensive or bilateral tears, associated urethral injury, delayed or missed diagnosis, and in some studies age over 50.[1,4]

What is the risk of erectile dysfunction?

Erectile dysfunction after a fracture may result from corporal scarring, impaired blood trapping, arterial or nerve injury, pain, anxiety, or a combination of physical and psychological factors. Prompt repair markedly reduces the risk compared with conservative management, but does not eliminate it.[1,3]

Persistent difficulty should be assessed rather than endured in silence. Evaluation can include a sexual and medical history, validated questionnaires, examination and, when indicated, penile Doppler ultrasound. Treatment is individualised and may include counselling, oral erectile-dysfunction medication when safe, vacuum therapy, injections or, rarely, reconstructive surgery or a penile prosthesis.

Does penile fracture cause Peyronie’s disease?

Healing after a penile fracture can produce a local scar, palpable nodule or post-traumatic curvature. These findings may resemble Peyronie’s disease, which is an acquired fibrotic disorder of the tunica albuginea. However, a curve after fracture should not automatically be labelled Peyronie’s disease: it may arise directly from the repaired tear, asymmetric healing or corporal fibrosis.

The distinction is made through history, examination and, if needed, photographs of the erect penis or ultrasound. Review is advisable if there is a new or worsening bend, a hard plaque, painful erections, loss of length, narrowing, instability or difficulty with intercourse. Management depends on whether the deformity is changing or stable, its severity, erectile function and how much it affects the patient. Options may include observation, penile traction in selected cases, treatment of erectile dysfunction, or reconstructive surgery once the deformity is stable. Treatment should be discussed with a urologist experienced in penile reconstruction or andrology.

The essential message

A suspected penile fracture is time-sensitive. A crack or pop followed by immediate loss of erection, swelling and bruising warrants immediate emergency assessment. Diagnosis is often clinical; ultrasound or MRI is reserved mainly for uncertainty, and the urethra must be assessed when injury is suspected. Prompt surgical repair offers the best prospect of preserving penile shape, erections and urinary function.

References

  1. European Association of Urology. EAU Guidelines on Urological Trauma. 2026 edition, sections on genital trauma and penile fracture. https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines
  2. Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. J Urol. 2014;192(2):327–335; amended guideline statements available from the American Urological Association. doi:10.1016/j.juro.2014.05.004. https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline
  3. Amer T, Wilson R, Chlosta P, et al. Penile fracture: a meta-analysis. Urol Int. 2016;96(3):315–329. doi:10.1159/000444884.
  4. Barros R, Schulze L, Ornellas AA, Koifman L, Favorito LA. Impact of surgical treatment of penile fracture on sexual function. Urology. 2019;126:128–133. doi:10.1016/j.urology.2018.11.027.
  5. Wong NC, Dason S, Bansal RK, Davies TO, Braga LH. Can it wait? A systematic review of immediate vs delayed surgical repair of penile fractures. Can Urol Assoc J. 2017;11(1–2):53–60. doi:10.5489/cuaj.4032.
  6. Koifman L, Barros R, Júnior RAS, Cavalcanti AG, Favorito LA. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology. 2010;76(6):1488–1492. doi:10.1016/j.urology.2010.05.043.

Website publication note

This material is general health information and was prepared from the sources listed above. It is not a substitute for emergency assessment, diagnosis, informed consent or personalised advice from a qualified practitioner. Outcomes and risks vary between individuals.

Tranexamic Acid for Radiation Cystitis: Benefits, Duration and Important Risks

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Blood in the urine after pelvic radiotherapy can be frightening. It may appear months or even many years after treatment for prostate, bladder, rectal or gynaecological cancer. One possible cause is radiation cystitis: delayed injury to the bladder lining and its small blood vessels.

Tranexamic acid is sometimes considered when bleeding is troublesome. It can help stabilise blood clots, but it does not repair the radiation injury itself and it is not suitable for every patient. In urinary tract bleeding, preventing a clot from dissolving may reduce bleeding but may also allow a larger clot to obstruct the bladder or ureter. Careful patient selection and medical supervision are therefore essential.

Seek urgent medical attention if you cannot pass urine, are passing large clots, feel faint or breathless, develop fever or flank pain, or the bleeding is heavy or worsening.

What is radiation cystitis?

Radiotherapy can cause progressive damage to the bladder’s small blood vessels. These vessels may become fragile and bleed easily. Patients may experience visible haematuria, urinary frequency, urgency, pain or recurrent clot retention.

Radiation cystitis should not be assumed simply because a patient has previously received radiotherapy. Infection, urinary stones, recurrent or new cancer, kidney disease and medication-related bleeding must also be considered. Assessment may include urine testing and culture, a full blood count, renal function, imaging of the upper urinary tract and cystoscopy. Biopsy is used selectively because irradiated tissue heals poorly.

How does tranexamic acid work?

The body normally breaks down blood clots through a process called fibrinolysis. Tranexamic acid blocks the binding of plasminogen and plasmin to fibrin, slowing this breakdown. It is therefore an antifibrinolytic medicine: it helps a clot remain in place rather than acting as a blood-clotting factor itself.

For radiation cystitis, tranexamic acid is intended to control active bleeding. It does not remove abnormal radiation-induced blood vessels, reverse fibrosis or prevent future bleeding once the medicine is stopped.

How effective is it for radiation cystitis?

The evidence is limited. Tranexamic acid has been used for haematuria from several causes, and a small randomised emergency-department study found that intravenous treatment reduced the amount of bladder irrigation required to clear the urine. However, it did not significantly reduce haemoglobin loss or transfusion requirements. Importantly, this study included mixed causes of haematuria and was not designed specifically for radiation cystitis.

The Canadian Urological Association best-practice report concluded that evidence was insufficient to make a formal recommendation for tranexamic acid in radiation-induced haemorrhagic cystitis. Later narrative reviews have reached a similar conclusion. Intravesical tranexamic acid, placed directly into the bladder, has shown encouraging results in small emergency-department studies of gross haematuria, but evidence specific to radiation cystitis is still inadequate and this remains a specialist, non-standard use.

In practice, tranexamic acid may be considered as a temporary adjunct in selected patients while the cause and severity of bleeding are assessed, or while more definitive treatment is arranged. It should not delay bladder washout, clot evacuation, cystoscopic treatment, hyperbaric oxygen therapy, embolisation or other appropriate care when these are required.

How long can tranexamic acid be used?

There is no well-supported universal duration for radiation cystitis. The Australian product information for oral tranexamic acid describes treatment of haematuria while blood remains macroscopically visible, but radiation cystitis is a recurrent condition and that instruction should not be interpreted as approval for indefinite therapy.

For this indication, treatment is generally best regarded as a short, medically supervised course for an active bleeding episode. The exact dose and duration depend on:

  • whether bleeding is mild, ongoing or causing clot retention;
  • whether the source is the bladder or upper urinary tract;
  • kidney function, because tranexamic acid is largely eliminated in the urine;
  • previous blood clots, cardiovascular risk and pro-thrombotic medicines;
  • anticoagulant or antiplatelet therapy; and
  • the response to treatment and need for definitive therapy.

There is no good evidence supporting continuous long-term tranexamic acid as prophylaxis for recurrent radiation cystitis. If bleeding has not clearly improved within a short course, recurs promptly after treatment, or requires repeated courses, the diagnosis and management plan should be reassessed. Longer or repeated use should occur only under specialist supervision, with renal function and thrombotic risk reviewed.

Patients should not start, extend, repeat or stop prescribed tranexamic acid without discussing it with their treating clinician.

Important side effects

Common or less serious adverse effects may include:

  • nausea, vomiting, diarrhoea or abdominal discomfort;
  • headache, dizziness or fatigue; and
  • muscle or joint discomfort.

Potentially serious adverse effects include:

Blood clots

Deep-vein thrombosis, pulmonary embolism, stroke, heart attack and other arterial or venous thromboses are uncommon but potentially serious. Risk assessment is particularly important in patients with an active or previous clot, known thrombophilia, active malignancy, prolonged immobility or concurrent pro-thrombotic medication.

Urgent assessment is required for new unilateral leg pain or swelling, sudden chest pain, shortness of breath, coughing blood, weakness on one side, difficulty speaking or sudden severe headache.

Clot retention and urinary obstruction

Tranexamic acid may stabilise clots within the urinary tract. This can contribute to painful bladder clot retention. It is particularly concerning when bleeding arises from a kidney or ureter, because a clot may obstruct the ureter and cause flank pain, hydronephrosis or loss of kidney function. Upper-tract haematuria therefore warrants particular caution and specialist assessment.

Kidney impairment

Most tranexamic acid is excreted unchanged through the kidneys. The dose must be reduced when renal function is impaired; accumulation increases the risk of toxicity, including neurological adverse effects. Significant renal impairment may make treatment inappropriate or require a substantially altered regimen.

Seizures

Seizures are a recognised, dose-related risk, reported particularly with high intravenous doses and when the medicine accumulates in renal impairment. A history of seizures requires careful consideration.

Visual disturbance

Rare visual effects, including altered colour vision, have been reported. New visual symptoms require prompt review and usually discontinuation pending medical advice. Ophthalmic monitoring may be considered when prolonged treatment is unavoidable.

Severe allergy

Facial or throat swelling, wheeze, breathing difficulty or a widespread blistering rash requires emergency care.

Who may not be suitable for treatment?

Tranexamic acid may be contraindicated or require particular caution in people with:

  • active thromboembolic disease or a substantial history or risk of thrombosis;
  • significant kidney impairment;
  • upper urinary tract bleeding or suspected ureteric obstruction;
  • a history of seizures;
  • acquired disturbances of colour vision;
  • disseminated intravascular coagulation unless managed by an experienced clinician; or
  • hypersensitivity to tranexamic acid.

Medication review is essential. Anticoagulants and antiplatelet agents can worsen bleeding, but stopping them may cause stroke, pulmonary embolism, heart attack or coronary-stent thrombosis. They should not be stopped merely because haematuria develops without an individual risk assessment involving the prescribing clinician. Likewise, combining tranexamic acid with pro-thrombotic medicines requires caution.

Where does it fit in the management pathway?

Management is guided by severity. Initial care may include resuscitation, correction of significant anaemia or coagulopathy, a large-bore catheter, manual washout and continuous bladder irrigation. Cystoscopy permits clot evacuation, exclusion of tumour and cautery or laser treatment of bleeding areas.

For persistent or recurrent radiation cystitis, options may include intravesical agents, hyperbaric oxygen therapy, selective arterial embolisation and, rarely, urinary diversion or cystectomy. Hyperbaric oxygen is one of the better-studied treatments because it aims to improve tissue oxygenation and new blood-vessel formation rather than merely suppressing an episode of bleeding.

Tranexamic acid may have a role as a bridge or adjunct in a carefully selected patient. Its value must always be balanced against the danger of thrombosis and urinary tract obstruction.

The take-home message

Tranexamic acid can reduce haematuria in some patients, but evidence specifically for radiation cystitis is weak. It is not a cure and should usually be used only for a short, active bleeding episode under medical supervision. There is no established safe or effective duration for continuous long-term use in radiation cystitis. Kidney function, clotting history, the anatomical source of bleeding and concurrent medication must be reviewed before treatment.

Visible haematuria after radiotherapy always deserves proper investigation, particularly if it is recurrent, contains clots or is accompanied by difficulty passing urine.

This article provides general information and does not replace individual medical advice. Tranexamic acid is a prescription medicine in Australia; its use for radiation cystitis must be individualised by the treating clinician.

References

  1. Goucher G, Saad F, Lukka H, Kapoor A. Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J. 2019;13(2):15–23. doi:10.5489/cuaj.5788
  2. Moharamzadeh P, Ojaghihaghighi S, Amjadi M, Rahmani F, Farjamnia A. Effect of tranexamic acid on gross hematuria: a pilot randomized clinical trial study. Am J Emerg Med. 2017;35(12):1922–1925. doi:10.1016/j.ajem.2017.09.012
  3. Abramowitz D, et al. Clinical management of radiation cystitis: a narrative review. AME Med J. 2021;6:30. Clinical management of radiation cystitis
  4. Choi H, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: a before-and-after study. Am J Emerg Med. 2023;68:118–122. doi:10.1016/j.ajem.2023.03.010
  5. Pfizer Australia. Cyklokapron (tranexamic acid) Australian Product Information. Current product information should be checked through the Therapeutic Goods Administration or the sponsor before prescribing. Australian product information
  6. DailyMed. Tranexamic acid injection—prescribing information. US National Library of Medicine. DailyMed drug labelling
  7. Chauncey JM, Wieters JS. Tranexamic Acid. In: StatPearls. Updated 2025. NCBI Bookshelf

 

Prostate Artery Embolisation: Who May Benefit, Important Caveats, and Can It Be Done After Radiotherapy?

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Lower urinary tract symptoms: poor flow, hesitancy, incomplete emptying, frequency, urgency and nocturia, are common as men age. When benign enlargement of the prostate (BPH) is genuinely responsible, treatment may include lifestyle measures, medication, minimally invasive procedures or surgery. Prostate artery embolisation (PAE) is one option that may be considered for appropriately assessed patients.

PAE is not simply a “smaller TURP”. It works differently, is performed by an experienced interventional radiologist, and has a different balance of benefits, limitations and risks. The most important question is not whether the prostate looks large, but whether prostatic obstruction is actually causing the patient’s symptoms.

What is prostate artery embolisation?

PAE is a minimally invasive, image-guided procedure. A small catheter is introduced through an artery, usually at the wrist or groin, and guided into the arteries supplying the prostate. Tiny permanent particles or, in selected expert practice, a liquid embolic agent are delivered to reduce blood flow to the hyperplastic prostate tissue. This causes controlled ischaemia, gradual shrinkage of the transition zone and reduced compression of the urethra.

The procedure can often be performed without a general anaesthetic and does not require instruments to pass through the urethra. Improvement, when it occurs, is usually progressive rather than immediate and may take several weeks or months. Results vary, and some men obtain little benefit or require another treatment.

Regulatory note for Australian readers: The TGA regulates therapeutic goods, including medicines and medical devices; it does not “approve” or endorse a medical procedure or an individual health service. References to PAE in this article should not be interpreted as TGA endorsement. Any embolic agent, catheter or other medical device used must be lawfully supplied in Australia and used in accordance with its applicable regulatory status, intended purpose and clinical governance requirements.

Important Wesley Hospital research

Associate Professor Nicholas Brown, an interventional radiologist affiliated with The University of Queensland and I-MED Radiology at The Wesley Hospital, led the following Australian studies of PAE.

The P-EASY ADVANCE randomised controlled trial, published in BJU International in 2024, compared PAE with combined tamsulosin and dutasteride therapy in 39 treatment-naïve men with enlarged prostates, moderate-to-severe symptoms and obstructed or equivocal urodynamic studies. At follow-up, 63% of men treated with PAE were urodynamically unobstructed, compared with 28% receiving medication. Within this study population and follow-up period, the PAE group had greater improvements in prostate volume, urinary flow, incomplete emptying, overall symptom score and quality of life. The trial was small, the estimates should not be generalised to every patient, and larger comparative trials with longer follow-up are required.

The follow-up P-EASY PLUS study, published in BJU International in 2025, assessed 105 men at a mean of 18 months. Mean prostate volume fell by 30.6%, total symptom scores improved by 55%, quality-of-life scores improved by 65.9%, and maximum urinary flow increased by 5 mL/second. Among the 57 men who completed paired urodynamic testing, the proportion classified as obstructed fell from 66.7% to 29.8%. No major procedural complication or new urinary incontinence was reported in this cohort; new retrograde ejaculation occurred in 2%. These are group-level study outcomes and do not guarantee an individual result. The authors noted that longer-term comparative research is required.

The P-EASY ADVANCE publication received the BJUI Global Prize for 2026. This statement describes the publication award only; it is not a patient-outcome claim, regulatory endorsement or guarantee of treatment effectiveness.

Author disclosure: I, Dr Joseph Schoeman, was a co-author of both Wesley Hospital studies. I performed some of the urodynamic studies for this article. Readers should take this relationship into account when considering the discussion. The results are reported with their limitations and placed alongside independent guidelines, randomised trials and systematic reviews. No patient testimonial or individual outcome has been used in this article.

Who may be a good candidate?

PAE may be considered when a man has:

  • bothersome moderate-to-severe urinary symptoms attributable to benign prostatic obstruction;
  • an enlarged prostate, particularly a moderately large or very large gland;
  • inadequate relief, unacceptable adverse effects or a preference not to take long-term medication;
  • a wish to avoid transurethral or more invasive surgery;
  • increased anaesthetic or surgical risk;
  • a preference for an option with lower reported rates of ejaculatory dysfunction or urinary incontinence in some studies, while recognising that these complications can still occur;
  • catheter-dependent urinary retention where obstruction from BPH is considered reversible and bladder contractility is adequate; or
  • recurrent or refractory bleeding shown to arise from the prostate in selected circumstances.

Current European Association of Urology guidance recommends offering PAE to men with moderate-to-severe LUTS due to benign prostatic obstruction who want a minimally invasive option and accept that outcomes may be less optimal than TURP. The American Urological Association also permits PAE as a treatment option when performed by appropriately trained clinicians, but grades the evidence as conditional.

What assessment is needed before PAE?

A large prostate does not prove obstruction, and urinary symptoms are not always caused by the prostate. Appropriate assessment may include:

  • symptom and quality-of-life scoring;
  • urinalysis and urine culture when indicated;
  • PSA assessment and prostate-cancer evaluation appropriate to age and risk;
  • digital rectal examination;
  • urinary flow rate and post-void residual measurement;
  • ultrasound or MRI assessment of prostate size and anatomy;
  • cystoscopy where haematuria, urethral stricture, bladder-neck pathology, stones or bladder disease is suspected;
  • urodynamic studies when the diagnosis is uncertain, symptoms are mixed, bladder contractility may be poor, or prior pelvic treatment has complicated the picture; and
  • CT or MR angiographic assessment of pelvic arterial anatomy, renal function and contrast risk when requested by the interventional radiologist.

The best decisions are generally made jointly by a urologist and an experienced PAE interventional radiologist.

Potential advantages of PAE

Potential advantages include:

  • no prostate tissue resection and usually no general anaesthetic;
  • day-stay or short hospital admission in many patients;
  • lower reported rates of major bleeding and transfusion than some operative procedures in comparative studies;
  • low reported, but not zero, rates of urinary incontinence;
  • a lower reported likelihood of retrograde ejaculation than with TURP or enucleation procedures in available studies;
  • usefulness in some very large prostates and medically complex patients; and
  • preservation of later surgical options if symptoms persist or recur.

Caveats: what PAE may not do as well

Compared with TURP or endoscopic enucleation, PAE generally produces a less immediate and less pronounced improvement in urinary flow and objective relief of obstruction. A Cochrane review found that short-term symptom improvement may be similar to TURP, but the certainty of evidence was low and retreatment may be more likely after PAE. Meta-analyses and longer-term randomised data generally show stronger objective improvement after TURP. Comparisons across studies must be interpreted cautiously because patient selection, technique, follow-up and outcome definitions differ.

PAE also does not provide prostate tissue for histology. Prostate cancer must therefore be considered and investigated before treatment rather than assumed to be excluded by a fall in prostate size or PSA afterward.

Technical success depends heavily on operator experience. Prostatic arteries are tiny, variable and sometimes severely atherosclerotic. Embolic material can rarely reach non-target vessels supplying the bladder, rectum or penis. Pre-procedure vascular imaging and cone-beam CT can reduce this risk but add iodinated contrast exposure and ionising radiation.

Side effects and complications

Common short-term effects form part of a post-embolisation syndrome and may include pelvic or perineal discomfort, urinary frequency and urgency, dysuria, fatigue, nausea, low-grade fever or a small amount of blood in the urine or semen. Temporary difficulty passing urine and the need for a catheter can occur.

Less common complications include urinary infection, access-site bruising or haematoma, contrast reaction, kidney injury, arterial injury, prostate infection or abscess, and passage of necrotic prostate tissue. Rare but important complications of non-target embolisation include ischaemic injury to the bladder, rectum or penis. Severe skin injury from fluoroscopic radiation is also rare but is a recognised procedural concern, particularly during prolonged or technically difficult cases.

Contraindications and reasons to pause

PAE is generally unsuitable, or requires correction and specialist review first, when there is:

  • an active urinary tract or systemic infection;
  • suspected or untreated prostate or bladder cancer requiring diagnostic clarification;
  • symptoms predominantly caused by urethral stricture, bladder-neck contracture, bladder stone, neurogenic dysfunction, overactive bladder or another non-BPH condition;
  • a poorly contractile or decompensated bladder unlikely to empty even if outlet resistance is reduced;
  • severe pelvic arterial atherosclerosis, occlusion, tortuosity or anatomy that prevents safe selective catheterisation;
  • an uncorrectable bleeding disorder;
  • a severe iodinated-contrast allergy that cannot be safely managed;
  • significant renal impairment where contrast risk is unacceptable; or
  • inability to tolerate arterial access, fluoroscopy or the required aftercare.

Small prostate size is not an absolute prohibition, but it makes careful confirmation of the cause of obstruction particularly important and may reduce the likelihood of benefit. A prominent obstructing median lobe is not automatically a contraindication in experienced hands, although prostate anatomy should be considered alongside all alternative treatments.

Can PAE be performed after prostate radiotherapy?

Potentially yes, but prior pelvic or prostate radiotherapy is not a routine indication, and the decision must be individualised. It is neither sensible to call radiotherapy an automatic absolute contraindication nor appropriate to assume that PAE will relieve every post-radiation urinary symptom.

After radiotherapy, poor flow, urgency, frequency, pain, retention or bleeding may result from:

  • persistent benign prostatic obstruction;
  • radiation cystitis and reduced bladder capacity;
  • detrusor overactivity or poor bladder contractility;
  • urethral stricture or bladder-neck stenosis;
  • prostate-cancer recurrence or progression;
  • infection, stones or clot retention; or
  • a combination of these problems.

PAE is most likely to help only when a meaningful component of the problem is supplied by vascular, enlarged prostate tissue or confirmed prostatic obstruction. It will not correct a urethral stricture, a scarred bladder neck, radiation cystitis, a small fibrotic low-capacity bladder or detrusor failure.

Evidence specifically studying PAE for BPH-type obstruction after completed radiotherapy is sparse. Most major BPH trials did not establish a dedicated post-radiotherapy evidence base. Radiotherapy can also alter pelvic tissues and small blood vessels, making angiographic anatomy and tissue response less predictable. For that reason, these patients should be assessed in a multidisciplinary setting and often benefit from cystoscopy, flow and residual testing, imaging and formal urodynamics before treatment.

PAE has been studied in men with prostate cancer and is being investigated before radiotherapy to reduce gland size and urinary symptoms. Embolisation has also been used for refractory bleeding of prostatic origin, including bleeding associated with malignancy or radiation. However, embolisation for life-threatening radiation-related haematuria may target vesical or other pelvic arteries and is a different clinical problem from PAE for benign outlet obstruction. These two indications should not be confused.

In a post-radiotherapy patient, PAE may therefore be reasonable when:

  1. recurrent cancer, infection and urethral or bladder-neck stenosis have been excluded or appropriately managed;
  2. investigations demonstrate an enlarged, vascular prostate with genuine outlet obstruction;
  3. bladder function is adequate enough to benefit from reducing resistance;
  4. pelvic arterial anatomy permits safe selective embolisation; and
  5. the patient understands that outcome data are limited and that further treatment may still be required.

How does PAE compare with surgery?

There is no universally “best” procedure. TURP, GreenLight laser, HoLEP or other enucleation procedures usually provide faster and more complete mechanical relief of obstruction. PAE is less invasive and some comparative studies report fewer ejaculatory or perioperative adverse effects; however, symptom relief can be slower, objective improvement may be smaller and retreatment may be more likely.

The right option depends on prostate size and configuration, the severity and cause of symptoms, bladder function, cancer risk, medical fitness, sexual priorities, arterial anatomy, previous pelvic treatment and the patient’s tolerance for the possibility of later retreatment.

The take-home message

PAE is an available treatment option for selected men with symptomatic benign prostatic obstruction. The Wesley Hospital P-EASY studies contribute Australian randomised and urodynamic data on symptoms, quality of life and obstruction, but their findings should be considered with the study designs, sample sizes, follow-up and declared author relationships.

It remains essential to diagnose the cause of symptoms before treating the scan. PAE is not a cure for every urinary problem and does not replace cancer assessment, cystoscopy or urodynamics when these are clinically indicated. After radiotherapy, PAE may be technically and clinically possible, but the evidence is limited and patient selection must be particularly rigorous.

References and further reading

  1. Brown N, et al. P-EASY ADVANCE: a randomised controlled trial of prostate embolisation versus medication for BPH. BJU International. 2024. doi: 10.1111/bju.16479.
  2. Brown N, et al. P-EASY PLUS: preliminary and follow-up urodynamic studies. BJU International. 2025. doi: 10.1111/bju.16808.
  3. Mark P, Brown NI, Ormiston WEL. Current considerations in prostate artery embolisation. CVIR Endovascular. 2026;9:45. doi: 10.1186/s42155-026-00689-5.
  4. European Association of Urology. Guidelines on the Management of Non-neurogenic Male LUTS: Disease Management. Current online edition accessed September 2026.
  5. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to BPH: AUA Guideline Amendment 2023. Journal of Urology. 2024;211:11–19. doi: 10.1097/JU.0000000000003698.
  6. Jung JH, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms in men with BPH. Cochrane Database of Systematic Reviews. 2022. Cochrane evidence summary.
  7. Müllhaupt G, et al. Prostatic artery embolisation versus TURP for benign prostatic obstruction: long-term outcomes of a randomised trial. European Urology. 2024. PubMed record.
  8. Zumstein V, et al. Prostatic artery embolization versus standard surgical treatment for LUTS secondary to BPH: systematic review and meta-analysis. European Urology Focus. 2019;5:1091–1100. doi: 10.1016/j.euf.2018.09.005.
  9. Parikh N, et al. Prostate artery embolization in the setting of prostate cancer. Seminars in Interventional Radiology. 2025. Full text.
  10. Kably I, et al. Prostatic artery embolization in refractory haematuria of prostatic origin. Techniques in Vascular and Interventional Radiology. 2020. PubMed record.
  11. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods. Updated 18 June 2026.
  12. Therapeutic Goods Administration. General requirements for advertising therapeutic goods to the public. Updated 11 March 2025.
  13. Australian Health Practitioner Regulation Agency. Advertising guidelines and other guidance. Accessed 22 September 2026.

Australian publication and advertising statement

This article is intended as balanced disease and treatment education. It does not advertise a named embolic product, catheter, medicine or device; offer an inducement; use testimonials; promise a cure; or claim that PAE is safe, risk-free, superior or effective in every case. Mention of the TGA, Ahpra, professional guidelines, a hospital, a journal or an award does not imply endorsement of this article, the author or the treatment.

Clinical claims are linked to identified publications and should be reviewed when the article is updated. Any future addition of brand names, booking prompts, prices, before-and-after images, patient stories, sponsored links or manufacturer-supplied material may change the regulatory character of the page and should undergo a fresh compliance review.

This article provides general information current at the stated review date and is not personal medical advice. It does not establish a doctor–patient relationship. Benefits and risks differ between individuals. Suitability for PAE should be decided after assessment by appropriately qualified clinicians, commonly including a urologist and an interventional radiologist. Patients should seek urgent medical care for inability to pass urine, fever or sepsis symptoms, severe pain, heavy bleeding or clot retention.

PAE BJU article

Blood in the Urine After Radiotherapy: Understanding Radiation Cystitis

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Pelvic radiotherapy is an important and often highly effective treatment for prostate, bladder, rectal and gynaecological cancers. However, radiation can leave the small blood vessels and lining of the bladder fragile. Months or even many years later, this may cause urinary symptoms or bleeding known as radiation cystitis. When bleeding is prominent, the condition is also called radiation-induced haemorrhagic cystitis.

Most episodes can be controlled, but visible blood in the urine must never simply be attributed to previous radiotherapy. Infection, urinary stones, recurrent cancer and a new bladder or upper urinary tract cancer must first be considered.

Seek urgent medical care if you cannot pass urine, are passing large clots, feel faint or short of breath, develop fever or severe pain, or have heavy ongoing bleeding.

What causes radiation cystitis?

Radiotherapy damages cancer cells, but the bladder may receive some radiation because it lies close to the treatment area. Early inflammation can make the bladder lining swollen and irritable. Late injury is different: progressive damage to small blood vessels causes reduced oxygen supply, scarring and fragile abnormal vessels called telangiectasia. These vessels may bleed with little provocation.

Radiation damage can also reduce bladder capacity and elasticity. In severe cases, ulceration, fibrosis, fistula formation or obstruction may occur.

When does it present?

Radiation-related bladder problems have two broad patterns:

  • Acute radiation cystitis occurs during radiotherapy or within the first few weeks or months. Frequency, urgency, burning and pelvic discomfort are common; substantial bleeding is less usual. Symptoms often settle after treatment finishes.
  • Late radiation cystitis generally begins more than six months after radiotherapy and may appear years or even decades later. The Canadian Urological Association review notes pathological vascular changes from about 6–12 months, with new symptoms reported as long as 20 years after treatment.

The risk varies with radiation dose and field, treatment technique, previous pelvic surgery, smoking, vascular disease, diabetes and combined cancer treatments.

How can it present?

Presentation ranges from microscopic blood found on a urine test to recurrent heavy bleeding with clots. Symptoms may include:

  • pink, red or cola-coloured urine;
  • small or large blood clots;
  • urinary frequency, urgency, burning or bladder pain;
  • interrupted flow or complete retention when clots obstruct the outlet;
  • tiredness, dizziness or breathlessness from anaemia; and
  • a small, painful or poorly compliant bladder in advanced disease.

Bleeding may be intermittent. A clear urine sample between episodes does not exclude radiation cystitis.

Does anticoagulant or antiplatelet therapy matter?

Anticoagulants such as warfarin, apixaban, rivaroxaban or dabigatran, and antiplatelet drugs such as aspirin or clopidogrel, do not create radiation cystitis. They can, however, make bleeding from its fragile vessels more prolonged or severe. Excess anticoagulation, impaired kidney function, drug interactions and combined anticoagulant–antiplatelet therapy can further increase bleeding risk.

These medicines may be preventing a stroke, heart attack, pulmonary embolus or thrombosis of a coronary stent. Do not stop them yourself. During significant bleeding, the urologist, emergency team and the clinician responsible for the medication should jointly balance:

  • the severity of bleeding and haemoglobin fall;
  • the reason for treatment and the risk of thrombosis if it is interrupted;
  • the last dose, kidney function and, for warfarin, the INR;
  • whether a temporary hold, reversal or dose adjustment is justified; and
  • when and how treatment should safely restart.

Importantly, anticoagulant or antiplatelet use does not remove the need to investigate haematuria. It may reveal bleeding from an otherwise silent bladder or upper-tract tumour.

How is haematuria investigated after radiotherapy?

Assessment is tailored to the patient and severity, but commonly includes:

  1. History and examination: radiation site, dose and timing; cancer history; smoking; infection symptoms; bleeding pattern; and all medicines.
  2. Urine testing: urinalysis and culture. Urine cytology may be appropriate in selected patients, but it does not replace cystoscopy.
  3. Blood tests: full blood count, kidney function and coagulation studies. Severe or ongoing bleeding may require group-and-screen or crossmatch.
  4. Imaging of the upper urinary tracts: usually CT urography when appropriate; ultrasound or alternative imaging may be chosen when contrast or radiation exposure is unsuitable.
  5. Cystoscopy: inspection of the urethra and bladder to identify typical diffuse telangiectasia, exclude a tumour, evacuate clots and sometimes cauterise bleeding vessels. Suspicious areas require biopsy, performed carefully because irradiated tissue heals poorly.

A stepwise approach to treatment

Treatment depends on the rate of bleeding, clot retention, anaemia, bladder function, medical fitness and local expertise. No single treatment suits every patient.

1. Stabilisation and bladder drainage

Heavy bleeding may require hospital admission, intravenous fluids, correction of anaemia or clotting abnormalities, and blood transfusion when clinically necessary. A large three-way catheter permits manual clot washout and continuous bladder irrigation with saline. Persistent clots may require cystoscopic evacuation under anaesthesia.

Treat a proven urinary infection, but antibiotics do not treat sterile radiation injury. Medication contributing to bleeding should be reviewed collaboratively rather than stopped automatically.

2. Cystoscopy and endoscopic haemostasis

Cystoscopy can confirm the diagnosis and exclude malignancy. Focal bleeding may be treated with diathermy, laser or another endoscopic coagulation technique. This is often effective initially, although diffuse disease may recur and repeated aggressive cautery can worsen scarring or perforation risk.

3. Intravesical and systemic options

Options used for persistent or recurrent bleeding include:

  • Alum bladder irrigation: may control bleeding relatively quickly, but recurrence is possible. It requires caution in substantial kidney impairment because aluminium toxicity can occur.
  • Hyaluronic acid, sometimes combined with chondroitin sulphate: aims to restore the bladder’s protective lining. Evidence suggests benefit for haematuria and urinary symptoms, but treatment is gradual and is not suitable for an unstable major bleed.
  • Oral sodium pentosan polysulphate: has limited, slower-onset evidence. Long-term exposure also requires discussion of pigmentary maculopathy and eye monitoring.
  • Other agents have been reported, but supporting evidence is generally limited.

Formalin can rapidly seal bleeding vessels but may cause severe pain, bladder contraction, reflux, ureteric damage, fistula or systemic complications. It is therefore reserved for life-threatening or otherwise uncontrollable bleeding, used at the lowest effective concentration by experienced teams after the upper tracts have been assessed and protected.

4. Hyperbaric oxygen therapy

Hyperbaric oxygen therapy (HBOT) is one of the best-studied treatments for persistent late radiation cystitis. The patient breathes 100% oxygen in a pressurised chamber. This increases tissue oxygen levels and encourages new blood-vessel growth and healing in chronically oxygen-deprived bladder tissue; it is not simply a short-lived attempt to “oxygenate the blood.”

How effective is it?

The evidence is encouraging, although success definitions and patient populations vary:

  • A meta-analysis cited by the Canadian Urological Association included 602 patients with at least one year of follow-up; 84% achieved partial or complete resolution of haematuria.
  • The multicentre randomised RICH-ART trial found a clinically meaningful improvement in patient-reported urinary symptoms after HBOT compared with standard care. At five years, 48 of 70 followed patients (68.6%) met the study’s responder definition, and the mean improvement among responders remained substantial. This supports durability for many—but not all—patients.
  • HBOT is not guaranteed. Some patients have incomplete improvement, relapse, or still require endoscopic or more invasive treatment. Earlier referral after recurrent bleeding may be preferable to waiting until the bladder is severely fibrotic or the patient has needed repeated transfusions.

How long does it take?

A usual course is 30–40 weekday sessions, sometimes more. Each treatment commonly involves approximately 80–90 minutes breathing oxygen at pressure, although total chamber time is longer. In practical terms, treatment usually takes six to eight weeks. Benefit may develop during the course and continue over subsequent weeks or months as tissue healing progresses.

HBOT is unsuitable or requires specialist assessment in some circumstances. An untreated pneumothorax is an absolute contraindication. Ear or sinus pressure injury, temporary visual change, claustrophobia and, rarely, oxygen-related seizure can occur. Lung disease, certain chemotherapy drugs, implanted devices and difficulty equalising ear pressure require individual review. Availability and daily travel are practical limitations.

5. Arterial embolisation

For ongoing significant bleeding despite less invasive measures, selective or super-selective embolisation can block the bleeding arterial supply. Modern targeted techniques reduce, but do not eliminate, risks such as pelvic pain, tissue ischaemia and non-target embolisation. It can be valuable in frail patients who are poor candidates for major surgery.

When should urinary diversion be considered?

Urinary diversion is a last-resort, potentially life-saving strategy, not an early treatment for uncomplicated bleeding. It should be discussed in a multidisciplinary setting at an experienced centre when there is:

  • life-threatening, transfusion-dependent or recurrent clotting haematuria despite endoscopic treatment, HBOT, appropriate intravesical therapy and/or embolisation;
  • a severely contracted, painful, non-functional bladder with intolerable frequency or poor storage;
  • fistula, necrosis, major outlet or ureteric damage, or progressive upper-tract deterioration;
  • repeated admissions and unacceptable loss of quality of life; or
  • inability to control bleeding safely by less invasive means.

Options include nephrostomy tubes or ureteric occlusion as temporary or palliative measures; cutaneous ureterostomy; or an ileal conduit. Diversion without removing the bladder may be considered in a very high-risk patient, but the retained irradiated bladder can continue to bleed, become infected or painful, and may later require surgery. Cystectomy with diversion provides definitive removal of the diseased bladder but is a major operation. Previous radiation makes tissue planes, healing and bowel surgery more difficult, so complication and mortality rates are substantially higher than for routine cystectomy.

The decision should incorporate the patient’s cancer status, cardiovascular and respiratory fitness, frailty, kidney and bowel function, previous operations, goals of care and willingness to manage a stoma or external drainage.

The practical message

Radiation cystitis may appear long after the original cancer treatment and can range from mild intermittent haematuria to a medical emergency. Blood-thinning medication may worsen the episode, but it should neither be blamed as the sole cause nor stopped without a coordinated medical plan. A careful evaluation to exclude malignancy and other treatable causes comes first.

Management is progressive: stabilisation and irrigation, cystoscopic treatment, selected bladder therapies, HBOT and embolisation before major diversion surgery. HBOT offers worthwhile, durable improvement for many appropriately selected patients, but requires a substantial weekday treatment commitment. Diversion is reserved for a devastated bladder or bleeding that remains dangerous despite comprehensive treatment.

References

  1. Goucher G, Saad F, Lukka H, Kapoor A. Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J. 2019;13(2):15–23. doi:10.5489/cuaj.5788
  2. Oscarsson N, Müller B, Rosén A, et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2–3 trial. Lancet Oncology. 2019;20(11):1602–1614. doi:10.1016/S1470-2045(19)30494-2
  3. Abramowitz DJ, Warner JN. Clinical management of radiation cystitis: a narrative review. AME Med J. 2021;6:9. doi:10.21037/amj-20-62
  4. Liem X, Saad F, Delouya G. A practical approach to the management of radiation-induced hemorrhagic cystitis. Drugs. 2015;75:1471–1482. doi:10.1007/s40265-015-0443-5
  5. Smit SG, Heyns CF. Management of radiation cystitis. Nat Rev Urol. 2010;7:206–214. doi:10.1038/nrurol.2010.23
  6. AUA/SUFU. Microhematuria Guideline (2020; amended 2025). American Urological Association. AUA guideline
  7. Oscarsson N, Rosén A, Müller B, et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): long-term follow-up of a randomised controlled, phase 2–3 trial. EClinicalMedicine. 2025;83:103214. doi:10.1016/j.eclinm.2025.103214
  8. Yang TK, Wang YJ, Li HJ, et al. Efficacy and safety of hyperbaric oxygen therapy for radiation-induced hemorrhagic cystitis: a systematic review and meta-analysis. J Clin Med. 2024;13(16):4724. doi:10.3390/jcm13164724

This article provides general information and does not replace individual medical advice. Treatment availability and suitability vary. Visible haematuria, particularly with clots or difficulty passing urine, requires prompt medical assessment.

Urinary Incontinence After Prostatectomy and Salvage Radiotherapy

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Why leakage may become more complex after both treatments

Urinary leakage after radical prostatectomy is common in the early recovery period and usually improves with healing and pelvic floor rehabilitation. Some men, however, require salvage radiotherapy because their PSA remains detectable or rises after surgery.

Radiotherapy can help control recurrent prostate cancer, but it may also affect tissues that have already been altered by surgery. Radiation can cause progressive scarring, reduced blood supply and loss of elasticity in the urethra, bladder neck and bladder. These effects may develop months or even years later.

As a result, leakage after prostatectomy and salvage radiotherapy is not always caused by a weak urinary sphincter alone. A man may have:

  • Stress urinary incontinence: leakage with coughing, standing, lifting, walking or exercise because the sphincter does not close effectively.
  • Urgency urinary incontinence: leakage accompanied by a sudden, difficult-to-defer urge, often caused by an overactive or irritated bladder.
  • Overflow leakage: leakage associated with poor bladder emptying, a weak bladder muscle or obstruction.
  • Mixed incontinence: a combination of stress and urgency leakage.
  • Radiation-related complications: bladder-neck contracture, urethral stricture, radiation cystitis, poor bladder compliance, fistula, tissue necrosis or, in severe cases, a severely damaged bladder outlet.

Correctly identifying the cause is essential. Tightening the outlet when the bladder cannot store or empty safely may replace one problem with another.

When should the problem be assessed?

Continence can continue to improve during the first year after prostatectomy. Pelvic floor muscle training should begin early, and surgical treatment may be considered as early as six months when severe leakage is clearly not improving. Persistent, bothersome stress incontinence at approximately 12 months deserves formal assessment.

Following salvage radiotherapy, earlier review is appropriate if there is:

  • worsening leakage;
  • blood in the urine;
  • recurrent urinary infection;
  • pain, burning or severe urgency;
  • a weak stream or difficulty emptying;
  • urinary retention;
  • pelvic or perineal pain; or
  • urine leaking through an abnormal opening.

Visible haematuria, fever, inability to pass urine or severe pain requires prompt medical attention.

Investigating incontinence after salvage radiotherapy

1. A careful history

The first step is to establish what type of leakage is occurring, when it began and whether it changed after radiotherapy. Important questions include:

  • Is leakage triggered by activity, or by urgency?
  • How many pads are used, and how wet are they?
  • Is the patient dry at night or when lying down?
  • Is there a weak stream, straining or incomplete emptying?
  • Are there recurrent infections, haematuria or pelvic pain?
  • Were there previous bladder-neck or urethral procedures?
  • How much does leakage affect work, exercise, sleep, intimacy and quality of life?

Manual dexterity and cognition are also important if an artificial urinary sphincter is being considered, because the patient must be able to locate and operate a small scrotal pump.

2. Bladder diary and pad assessment

A three-day bladder diary records fluid intake, voided volumes, urgency and leakage. Pad number gives a useful impression, but pads differ greatly. A 24-hour pad-weight test can quantify the actual volume lost and help grade severity and monitor progress.

3. Examination and basic tests

Assessment commonly includes:

  • abdominal, genital, perineal and neurological examination;
  • observation for leakage while coughing or standing with a comfortably full bladder;
  • urinalysis and urine culture when infection is suspected;
  • uroflowmetry;
  • ultrasound measurement of the post-void residual; and
  • renal function testing or upper-tract imaging when clinically indicated.

4. Cystoscopy

Cystoscopy is particularly important before continence surgery in a previously irradiated urinary tract. It allows the urologist to inspect the urethra, bladder neck and bladder for:

  • urethral stricture or bladder-neck contracture;
  • radiation damage, stones or tumour;
  • erosion from a previous implant;
  • tissue quality and sphincter appearance; and
  • fistula or necrosis in complex cases.

Any clinically important obstruction or unstable urethral disease usually needs to be treated and shown to be stable before an anti-incontinence device is implanted.

What is the role of urodynamic studies?

Urodynamics is not mandatory for every man with straightforward stress leakage. It becomes more useful when symptoms are mixed, the diagnosis is uncertain, previous radiation has made the situation more complex, or the result may change treatment.

The study can assess:

  • stress leakage and sphincter weakness;
  • involuntary bladder contractions;
  • bladder capacity and sensation;
  • reduced bladder compliance or unsafe storage pressures;
  • obstruction;
  • weak bladder contraction; and
  • the ability of the bladder to empty against a future sling or sphincter cuff.

Urodynamics is especially worth considering when there is marked urgency, nocturnal leakage, retention, a raised residual, poor flow, recurrent infection, prior outlet reconstruction or concern about a small, painful or poorly compliant radiation-damaged bladder.

The test does not simply decide whether a man “qualifies” for an operation. Its value is in identifying bladder dysfunction that should be treated first or a bladder that may not tolerate additional outlet resistance.

Initial and non-surgical management

Pelvic floor rehabilitation

Supervised pelvic floor muscle training can improve control and teach correct muscle activation. It is most useful early after prostatectomy but may still improve coping and control later. Repeated forceful exercises are not always better; poor technique can worsen pelvic tension or urgency.

Bladder and lifestyle measures

Management may include weight reduction where relevant, treating constipation, moderating caffeine and alcohol, adjusting the timing of fluids and diuretics, bladder training and treating urinary infection. Antimuscarinic medication or a beta-3 agonist may help an overactive-bladder component, but medication does not restore a damaged sphincter.

Pads, sheaths and clamps

Absorbent pads remain a practical option for mild leakage or while awaiting treatment. A condom drainage sheath can direct urine into a leg bag when penile skin and anatomy permit.

A penile clamp may provide short-term control for selected men with good sensation, intact skin and adequate bladder emptying. It must be released regularly and should not be used overnight. Extra caution is required after radiation because pressure injury may heal poorly.

Catheter options

Catheters manage drainage; they do not repair stress incontinence. They may nevertheless be appropriate when there is retention, very poor emptying, severe frailty, failed reconstruction or a need for temporary urinary control.

Intermittent self-catheterisation

Intermittent self-catheterisation is generally preferred when the bladder fails to empty but the patient has sufficient dexterity and urethral access. It avoids a continuously indwelling tube, although irradiated strictures or a false passage may make catheterisation difficult.

Long-term urethral catheter

An indwelling urethral catheter may be necessary in selected patients, but long-term use can cause infection, discomfort, blockage, bladder stones, urethral erosion and further outlet damage. A catheter passing through an activated AUS cuff can also cause serious urethral erosion; healthcare providers must be told that an AUS is present and the device should be deactivated before urethral instrumentation.

Suprapubic catheter

A suprapubic catheter enters the bladder through the lower abdomen. For long-term drainage it often avoids continuing urethral pressure and may be easier to manage than a urethral catheter. It still requires regular changes and carries risks including infection, blockage, bladder stones, leakage and skin problems.

Male sling versus artificial urinary sphincter

Male sling

A male sling supports and repositions or compresses the urethra. Its advantages include no scrotal pump and no need to operate the device each time the patient urinates. In carefully selected, non-irradiated men with mild-to-moderate stress incontinence, a sling can be effective.

However, previous pelvic radiotherapy is a recognised predictor of poorer sling outcomes. Fibrosis limits urethral mobility and tissue recovery, and moderate-to-severe leakage further reduces success. A sling may still be discussed in a highly selected patient with very mild leakage, good residual sphincter function and a stable, healthy-looking urethra, but expectations must be conservative.

Artificial urinary sphincter (AUS)

The AUS consists of a fluid-filled cuff around the urethra, a pressure-regulating balloon and a pump in the scrotum. The cuff stays closed to control leakage. The patient squeezes the pump to open it temporarily when passing urine.

For men with moderate-to-severe stress incontinence, the AUS remains the most established surgical treatment. Importantly, the AUA/GURS/SUFU guideline recommends offering an AUS rather than a male sling or adjustable balloons to men seeking surgery after primary, adjuvant or salvage radiotherapy.

Radiation does not make AUS implantation impossible, but outcomes are less predictable than in non-irradiated men. Radiation increases the risks of urethral erosion, infection, tissue atrophy, revision and device removal. Mechanical parts also have a limited lifespan, so further surgery may eventually be required.

Practical comparison

Consideration Male sling Artificial urinary sphincter
Best-established role Mild-to-moderate stress leakage in selected men Moderate-to-severe stress leakage
Previous salvage radiotherapy Lower success; generally not preferred Guideline-preferred surgical option, with higher complication risk than in non-irradiated men
Patient operation No pump Scrotal pump must be squeezed for each void
Manual dexterity required Minimal Yes
Retention risk Possible Possible if device is not cycled correctly or obstruction develops
Long-term considerations Persistent leakage or failure may require AUS Mechanical failure, erosion, infection or atrophy may require revision or removal

Neither operation guarantees complete dryness. The choice should consider pad weight, bladder function, urethral health, prior strictures or surgery, dexterity, patient priorities and the reconstructive surgeon’s assessment.

When an AUS or sling is not enough

A small group of men develop a severely scarred, painful or repeatedly obstructed outlet, sometimes called a devastated bladder outlet. This may include recurrent bladder-neck contracture or urethral stricture, fistula, radionecrosis, repeated AUS erosion, severe radiation cystitis or an unsafe low-capacity bladder.

Further implant surgery may then be unlikely to succeed. The priority changes from preserving normal voiding to obtaining dependable drainage, protecting the kidneys and improving quality of life.

Options at a specialist reconstructive centre may include:

  • long-term suprapubic drainage;
  • closure of the bladder neck with a suprapubic catheter in selected cases;
  • a catheterisable abdominal channel in carefully selected patients;
  • an ileal conduit, in which urine drains through a short segment of bowel to a urostomy bag on the abdomen;
  • another form of continent urinary diversion in selected fit patients; or
  • cystectomy with urinary diversion when the bladder is severely painful, contracted, bleeding, fistulating or otherwise unsalvageable.

These are major, irreversible procedures with substantial risks. They should be considered only after detailed imaging and functional assessment, review of cancer status, discussion with an experienced reconstructive team and consultation with a stomal therapy nurse.

A sensible treatment pathway

  1. Define the leakage: stress, urgency, overflow or mixed.
  2. Measure its severity: diary, pads and preferably pad weight.
  3. Check storage and emptying: urine testing, flow and residual; use urodynamics when the findings may alter treatment.
  4. Inspect the outlet: cystoscopy before implant surgery, particularly after radiation.
  5. Treat infection, obstruction and bladder dysfunction first.
  6. Use conservative or catheter strategies when appropriate.
  7. For persistent radiated stress incontinence, discuss AUS as the usual preferred operation.
  8. Reserve sling surgery for exceptional, carefully selected radiated patients after frank counselling.
  9. Refer severe outlet or bladder destruction to a high-volume reconstructive centre to discuss reconstruction versus diversion.

The take-home message

Urinary incontinence after prostatectomy and salvage radiotherapy is treatable, but it needs more than a pad count and a one-size-fits-all operation. The bladder, sphincter and urethra must each be assessed.

For straightforward sphincter weakness after radiation, the artificial urinary sphincter usually offers the most reliable surgical option, although radiation increases the likelihood of erosion and future revision. A male sling is less invasive but is less dependable in irradiated tissue. When the outlet or bladder is severely damaged, catheter drainage, bladder-neck closure or urinary diversion may provide a safer and more durable solution than repeated continence procedures.

This article provides general information and does not replace an individual assessment. Treatment should be tailored to the patient’s symptoms, examination, bladder function, urethral condition, cancer status and personal priorities.

References

  1. Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024). Journal of Urology. 2024. AUA guideline | Journal update
  2. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms: urinary incontinence assessment and treatment. Current online edition. EAU guideline
  3. American Urological Association, ASTRO and SUO. Salvage Therapy for Prostate Cancer Guideline. AUA/ASTRO/SUO salvage therapy guideline
  4. National Institute of Diabetes and Digestive and Kidney Diseases. Urodynamic testing. NIDDK patient information
  5. British Association of Urological Surgeons. Urinary diversion into an ileal conduit. BAUS patient information

Evidence note: Most data specific to men who have undergone both prostatectomy and salvage radiotherapy come from observational series rather than large randomised trials. Recommendations therefore combine guideline evidence, reconstructive-urology experience and individualised shared decision-making.

Radical Prostatectomy After Radiation Therapy for Prostate Cancer

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When prostate cancer returns after radiotherapy

Radiotherapy, whether external-beam radiation or brachytherapy can provide excellent long-term control of localised prostate cancer. However, a rising prostate-specific antigen (PSA) after treatment may indicate that the cancer has returned.

This does not automatically mean that the cancer is still in the prostate, nor does every PSA rise require immediate treatment. Recurrence may be confined to the prostate, present in lymph nodes or bones, or involve more than one site. Some recurrences also progress slowly enough that surveillance may be appropriate.

When clinically significant cancer is proven to have returned within the irradiated prostate, with no evidence of spread elsewhere, removal of the prostate may still offer a chance of cure. This operation is called a salvage radical prostatectomy.

What is a salvage radical prostatectomy?

A salvage radical prostatectomy removes the entire prostate and seminal vesicles after previous prostate radiotherapy. Depending on the cancer and imaging findings, pelvic lymph nodes may also be removed.

The operation may be performed using robotic-assisted or open surgery. A robotic approach can improve magnification and access, but it does not remove the biological effects of previous radiation. Surgeon and centre experience are therefore more important than the label attached to the surgical technique.

Salvage surgery is technically more difficult than a prostatectomy performed before radiotherapy. Radiation can cause:

  • scarring and fibrosis around the prostate;
  • loss of the normal tissue planes between the prostate, bladder and rectum;
  • reduced tissue blood supply;
  • poorer tissue healing; and
  • pre-existing damage to urinary, erectile or bowel function.

For these reasons, salvage prostatectomy should generally be undertaken in a centre with specific experience in complex prostate cancer surgery and access to multidisciplinary care.

When might salvage surgery be considered?

The aim is to identify a man who has a meaningful risk from his recurrent cancer, but whose disease still appears curable with local treatment. Possible indications include:

  • a rising PSA after radiotherapy, commonly assessed using the Phoenix definition: a PSA rise of at least 2 ng/mL above the lowest PSA reached after treatment;
  • prostate cancer confirmed on biopsy after radiotherapy;
  • imaging suggesting that the recurrence is confined to the prostate or immediate surrounding tissues;
  • no evidence of distant metastatic disease;
  • a life expectancy long enough to benefit from curative treatment, often more than 10 years;
  • good general health and fitness for major surgery;
  • acceptable baseline bladder function; and
  • willingness to accept a higher risk of urinary and sexual side effects than with a primary prostatectomy.

Factors such as the PSA level, PSA doubling time, interval since radiotherapy, biopsy Grade Group, clinical stage and the original cancer characteristics help estimate whether salvage treatment is likely to be worthwhile.

Assessment before considering surgery

A rising PSA is the beginning of the assessment—not the final diagnosis. Investigations commonly include:

Review of the original treatment

The radiation dose and field, use of brachytherapy, previous androgen-deprivation therapy, original biopsy grade and pre-treatment imaging should all be reviewed.

Multiparametric MRI

MRI can help identify the site and extent of a local recurrence, assess the seminal vesicles, bladder neck and rectal interface, and guide biopsy. Interpretation after radiation can be challenging and benefits from specialist radiological expertise.

PSMA PET/CT

PSMA PET/CT is used to look for disease in lymph nodes, bones or other organs. Finding metastatic disease usually changes the treatment plan and may mean that removing the prostate would not provide the expected benefit. Very small-volume disease can still be below the resolution of any scan.

Prostate biopsy

Major guidelines recommend pathological confirmation before potentially morbid local salvage therapy. Biopsy can confirm viable cancer, determine its grade and help distinguish clinically important recurrence from post-radiation change. Both targeted and systematic sampling may be considered.

Urinary-function assessment

Assessment may include symptom scores, urine testing, urinary-flow measurement, residual urine ultrasound and cystoscopy. Urodynamic testing may be helpful when there is significant urgency, leakage, poor flow, retention or uncertainty about bladder function.

Who may not be a good candidate?

Salvage prostatectomy is less likely to be appropriate when:

  • metastatic or extensive nodal disease is present;
  • the cancer is unlikely to be completely removable;
  • life expectancy is limited by age, frailty or other illness;
  • the recurrence is low risk and unlikely to threaten health;
  • severe urinary or bowel damage already exists after radiation; or
  • the anticipated harms of surgery outweigh the probability of cancer control.

These are not absolute rules. Individual circumstances should be reviewed by a multidisciplinary team involving urology, radiation oncology, medical oncology, radiology and pathology.

What are the potential benefits?

For carefully selected men, salvage prostatectomy can:

  • remove the recurrent cancer and provide complete pathological staging;
  • provide durable PSA control without immediately committing the patient to lifelong hormonal therapy; and
  • offer a possibility of cure when disease is truly confined to the prostate.

Published results vary considerably because most evidence comes from retrospective series involving highly selected patients. The European Association of Urology reports five-year biochemical recurrence-free estimates broadly around 41–52% in a large contemporary systematic review, while older selected series have reported ranges of approximately 47–82%. A broader meta-analysis of all local salvage approaches found roughly 50–60% five-year recurrence-free survival, without clear evidence that one approach was oncologically superior. These figures should not be interpreted as a personal prediction.

Cancer control is generally more favourable when the PSA is lower, the recurrent tumour is organ-confined, the cancer grade is lower, the PSA doubling time is longer and there is no nodal or distant disease.

Side effects and complications

Complication rates vary with baseline function, radiation type and dose, disease extent, surgical technique, definitions used in studies and surgeon experience. Results from specialist centres may not apply everywhere.

Urinary incontinence

Loss of urinary control is one of the most important risks. Radiation may already have affected the sphincter, bladder and urethral tissues, and surgery removes the prostate through which the urethra passes.

Leakage may range from mild stress incontinence to severe continuous leakage. Pelvic-floor rehabilitation can help, but some men may later require a male sling or artificial urinary sphincter. Continence outcomes reported in the literature vary widely because studies use different definitions; the risk of significant or persistent leakage is clearly higher than after primary prostatectomy.

Erectile dysfunction

Erectile function is often already impaired by radiotherapy, age, vascular disease or hormonal treatment. Preservation of the erectile nerves may be unsafe or technically impossible because of tumour location and radiation fibrosis. Consequently, erectile dysfunction after salvage prostatectomy is very common and recovery of unassisted erections is uncommon.

Rehabilitation and treatment options include tablets, vacuum devices, penile injections and penile prosthesis surgery. As with any radical prostatectomy, ejaculation and natural fertility are lost because the prostate and seminal vesicles are removed.

Bladder-neck contracture or urethral narrowing

Scar tissue may develop where the bladder is reconnected to the urethra. This can cause a weak stream, straining, incomplete emptying, retention or recurrent infection. Treatment may require endoscopic incision or dilatation, sometimes more than once. Repeated procedures can worsen incontinence.

Urine leak and delayed healing

The new bladder-to-urethra join may heal slowly because irradiated tissues have reduced blood supply. A urinary catheter may need to remain in place longer, and imaging may be required before its removal. Persistent leakage can require drainage or further intervention.

Rectal injury and urinary fistula

The rectum can be densely adherent to the prostate after radiotherapy. Rectal injury is uncommon in expert contemporary practice but occurs more often than during primary prostatectomy and can be serious. It may require repair, temporary bowel diversion or, rarely, more extensive surgery. An abnormal connection between the urinary tract and rectum—a rectourinary fistula—is rare but particularly difficult to treat.

Other surgical risks

Other possible complications include bleeding or transfusion, infection, blood clots, lymphocele after lymph-node dissection, injury to nearby structures, anaesthetic complications, chronic pelvic pain and the need for further procedures.

Cancer may still recur

Even when preoperative imaging suggests local disease, microscopic cancer may already exist outside the prostate. PSA may therefore remain detectable or rise again after surgery. Further treatment—such as hormonal therapy, systemic therapy or selected metastasis-directed treatment—may still be required.

Are there alternatives?

Depending on the cancer, previous treatment, anatomy, urinary function and patient priorities, alternatives may include:

  • active monitoring for a slow or low-risk recurrence;
  • androgen-deprivation therapy, sometimes with additional systemic treatment;
  • salvage brachytherapy or stereotactic re-irradiation;
  • cryotherapy;
  • high-intensity focused ultrasound (HIFU); or
  • focal salvage treatment in carefully selected cases.

No single salvage treatment is best for every patient. Available studies are mostly non-randomised and use differing definitions. A large meta-analysis found broadly similar five-year cancer control among local salvage methods, but severe urinary toxicity was higher after salvage prostatectomy than after modern re-irradiation approaches. Treatment should therefore be selected through shared decision-making rather than on cancer-control figures alone.

The bottom line

Radical prostatectomy after prostate radiotherapy is possible and can be curative, but it is not a routine operation. The best candidate is generally a fit man with biopsy-proven, clinically significant recurrence confined to the prostate, no metastatic disease on appropriate staging, a meaningful life expectancy and a clear understanding of the potential functional consequences.

Accurate staging, confirmation by biopsy, assessment of baseline urinary function and review by an experienced multidisciplinary team are essential. The decision must balance the chance of durable cancer control against the higher risks of urinary incontinence, erectile dysfunction, urinary narrowing, poor healing and rectal complications.

This article provides general information and does not replace individual medical advice. Recommendations should be tailored to the pathology, imaging, previous radiation treatment, general health and preferences of each patient.

References

  1. European Association of Urology. EAU Guidelines on Prostate Cancer: Treatment—management of PSA failure after radiation therapy and salvage radical prostatectomy. Current online edition. https://uroweb.org/guidelines/prostate-cancer/chapter/treatment
  2. Morgan TM, et al. Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline. Journal of Urology. 2024. https://www.auanet.org/guidelines-and-quality/guidelines/salvage-therapy-for-prostate-cancer
  3. Valle LF, et al. A systematic review and meta-analysis of local salvage therapies after radiotherapy for prostate cancer (MASTER). European Urology. 2021;80(3):280–292. doi:10.1016/j.eururo.2020.11.010.
  4. Grubmüller B, et al. Salvage radical prostatectomy for radio-recurrent prostate cancer: an updated systematic review of oncological, histopathological and functional outcomes and predictors. European Urology Focus. 2021;7(5):967–978.
  5. Perera M, et al. Morbidity of salvage radical prostatectomy: limited impact of the minimally invasive approach. European Urology Open Science. 2022;39:64–72.
  6. Zumsteg ZS, et al. The natural history and predictors of outcome following biochemical relapse in the dose-escalation era for prostate cancer patients undergoing definitive external beam radiotherapy. European Urology. 2015;67(6):1009–1016.

 

Focal Laser Therapy for Localised Prostate Cancer: What Do We Know?

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Focal therapy is an evolving approach to treating selected prostate cancers. Instead of treating or removing the entire prostate, it aims to destroy the identified cancer while preserving as much surrounding prostate tissue as possible.

One technique under investigation uses laser energy delivered through a fine fibre placed into the prostate. Early clinical reports are encouraging, but focal laser therapy is not suitable for every cancer and long-term evidence remains limited compared with established treatments such as radical prostatectomy and radiotherapy.

This article explains the disease, the principle of focal laser ablation, the early Guy’s Hospital pilot and the questions patients should consider before choosing treatment. It does not recommend a particular product, device or provider.

Understanding localised prostate cancer

Localised prostate cancer appears confined to the prostate on the available investigations. However, cancers vary greatly in their grade, size, position and biological behaviour.

Assessment commonly considers:

  • PSA level and PSA density
  • digital rectal examination findings
  • multiparametric prostate MRI
  • prostate-biopsy grade, often reported using Grade Group
  • number, position and extent of positive biopsy cores
  • whether clinically significant cancer is present in one or several parts of the prostate
  • the patient’s age, health, life expectancy and preferences
  • staging investigations where indicated

Some low-risk cancers may be monitored safely with active surveillance. Other cancers require treatment because their features suggest a meaningful risk of growth or spread.

What is focal therapy?

Focal therapy treats the known area of clinically significant cancer rather than the whole prostate. Depending on the extent and location of disease, treatment may target a small focus, a larger region or one side of the gland.

Energy sources used or investigated for focal therapy include:

  • high-intensity focused ultrasound
  • cryotherapy
  • irreversible electroporation
  • focal laser ablation
  • other thermal or energy-based techniques

These methods are not interchangeable. Each has different equipment, treatment planning, evidence, limitations and regulatory status.

How does focal laser ablation work?

Focal laser ablation delivers laser energy through a thin fibre positioned within the planned treatment area. The energy heats and destroys targeted tissue.

Placement may be performed through the perineum, the area between the scrotum and anus, with MRI and ultrasound information used to guide treatment planning and positioning. Temperature monitoring, cooling systems or other safeguards may be used according to the particular technique.

The intended advantage is to treat the cancer focus while reducing injury to structures involved in urinary continence, erections and bowel function. This is a treatment aim, not a guarantee. Damage to surrounding tissue and functional side effects remain possible.

What did the Guy’s Hospital pilot report?

Guy’s Hospital in London began a pilot involving 30 patients with localised prostate cancer. According to the hospital information reported by the BBC, assessment of the first 10 treated patients found no remaining cancer in the treated area in eight, while two had a small amount of residual cancer.

These figures should be interpreted cautiously:

  • they concern only the first 10 patients of a small pilot
  • they describe early findings in the treated area, not long-term cure
  • cancer may be present elsewhere in the prostate
  • follow-up was not long enough to establish durability, metastasis prevention or survival benefit
  • results from carefully selected research participants may not apply to all patients

The pilot includes ongoing follow-up, including imaging. Larger studies, longer observation and peer-reviewed comparative evidence are needed before firm conclusions can be drawn about long-term cancer control and functional outcomes.

Who might be considered for focal therapy?

Focal therapy may be discussed for carefully selected patients whose clinically significant cancer can be identified and targeted while untreated areas can be monitored reliably.

Selection may take account of:

  • MRI-visible disease
  • biopsy confirmation and cancer grade
  • location, volume and number of cancer foci
  • proximity to the urethra, urinary sphincter, rectum and neurovascular structures
  • prostate size and anatomy
  • previous prostate treatment
  • ability and willingness to undergo close follow-up and repeat biopsy
  • availability of appropriate expertise and governance

Multifocal, poorly defined, extensive or higher-risk cancer may make a focal approach unsuitable. An apparently single MRI lesion does not prove that no important cancer exists elsewhere in the gland.

What assessment is needed beforehand?

Accurate mapping of the cancer is essential. Depending on the patient, assessment may include:

  • review of PSA history
  • high-quality multiparametric MRI
  • targeted and systematic transperineal biopsy
  • expert radiology and pathology review
  • staging imaging when indicated by risk
  • baseline urinary, erectile and bowel function assessment
  • discussion by a multidisciplinary prostate-cancer team

A treatment decision should not be based on MRI alone. Biopsy remains important for confirming the grade and distribution of cancer.

Potential advantages

Possible advantages for appropriately selected patients include:

  • treatment directed at the known cancer rather than the entire prostate
  • usually a shorter procedure and recovery than radical prostatectomy
  • potential for same-day discharge
  • a lower treatment burden for some patients
  • the possibility of preserving urinary and sexual function more often than with whole-gland treatment
  • retention of other treatment options if further cancer is later detected

These are potential advantages, not assured outcomes. Comparisons with surgery or radiotherapy are difficult because patient selection, outcome definitions and follow-up periods differ across studies.

Risks and limitations

Possible complications include:

  • blood in the urine or semen
  • discomfort, bruising or swelling
  • urinary infection
  • difficulty passing urine or temporary catheterisation
  • urinary retention
  • urethral narrowing
  • urinary urgency or leakage
  • erectile or ejaculatory changes
  • injury to tissue surrounding the prostate
  • residual cancer within the treated area
  • clinically significant cancer elsewhere in the prostate
  • need for repeat focal treatment or conversion to surgery or radiotherapy

Rare but serious complications may occur. The specific risk profile depends on the technology, treatment location, operator experience and individual anatomy.

Focal therapy does not remove the need for surveillance

Unlike radical prostatectomy, focal therapy leaves prostate tissue behind. PSA therefore remains detectable and cannot be interpreted in the same way as after complete prostate removal.

Follow-up may include:

  • regular PSA testing
  • clinical review
  • repeat MRI
  • targeted and systematic repeat biopsy
  • assessment of urinary and sexual function

Imaging alone may not exclude residual or recurrent cancer. Patients need to be willing to undergo structured, long-term surveillance and possible further biopsy or treatment.

How does it compare with established options?

Active surveillance

Active surveillance avoids or delays treatment in suitable patients with lower-risk disease. It involves scheduled PSA tests, MRI, examination and repeat biopsy. It avoids immediate treatment side effects but carries the burden of monitoring and the possibility that treatment will later be required.

Radical prostatectomy

Surgery removes the prostate and seminal vesicles and provides complete pathological assessment of the removed gland. It has extensive long-term evidence for selected patients but may cause urinary incontinence, erectile dysfunction, loss of ejaculation and other surgical complications.

Radiotherapy

External-beam radiotherapy and brachytherapy are established treatments for localised prostate cancer. Risks may include urinary, bowel and sexual effects, which can develop during treatment or later. Some patients also require androgen-deprivation therapy.

Focal therapy

Focal therapy attempts to balance cancer control with preservation of function. Its principal uncertainties are the selection of suitable patients, untreated cancer elsewhere in the prostate, definitions of treatment success and the lack of mature comparative and long-term cancer-control data.

What happens if cancer remains or returns?

Further management depends on the location and risk of the cancer, previous treatment and patient preference. Options may include:

  • continued surveillance in selected circumstances
  • repeat focal treatment
  • radical prostatectomy
  • radiotherapy
  • another appropriate cancer treatment

Salvage treatment after focal therapy may be technically more complex and can have different side-effect rates from primary treatment. Patients should discuss the available rescue options before choosing focal therapy, not only after treatment failure.

Australian regulatory status and access

Regulatory status, approved indications, availability, reimbursement and participation in clinical trials can change. A device being used in research overseas does not automatically mean that the same system is approved, routinely available or publicly funded in Australia.

Patients considering a particular technology should ask:

  • Is the exact device included in the Australian Register of Therapeutic Goods for the proposed use?
  • Is treatment being offered as standard care, through a clinical trial or under another access pathway?
  • What evidence supports this technique for my particular cancer?
  • What costs and follow-up procedures are involved?
  • Who will manage surveillance and any residual or recurrent cancer?

Current regulatory information should be confirmed directly through the Therapeutic Goods Administration and the treating institution. This article does not make a claim that any named focal-laser system is TGA approved.

Questions to ask your prostate-cancer team

  • What is my Grade Group and clinical risk category?
  • Is the cancer confined to one clearly targetable area?
  • How confident are we that significant cancer is not present elsewhere?
  • Is active surveillance a safe option for me?
  • What are the established alternatives and their long-term outcomes?
  • What evidence is available for this focal technique?
  • How will success be measured?
  • Will I need another biopsy?
  • What are the urinary, sexual and bowel risks?
  • What happens if the cancer is not completely treated or later recurs?
  • Is this standard treatment or part of a research study?

The bottom line

The early Guy’s Hospital experience adds to growing interest in focal laser treatment for localised prostate cancer. The reported initial findings are encouraging, but 10 early cases cannot establish long-term cure, comparative effectiveness or safety.

Focal therapy may be reasonable to discuss for carefully selected patients who understand the uncertainties and accept close surveillance. It should be considered alongside active surveillance, surgery and radiotherapy through shared decision-making with an experienced multidisciplinary team.

This article provides general disease education. It does not recommend or promote a particular therapeutic device, treatment system, clinician or health service and does not replace individual medical advice. Regulatory status and clinical evidence should be checked at the time treatment is considered.

References and further reading

Publication note

This is an original educational article, not a republication of the BBC report.