Imaging of surgical bed complications after prostatectomy and radiation therapy

Radical prostatectomy and radiation therapy, which are standard treatments for prostate cancer, are associated with various short- and long-term complications. Early post-prostatectomy complications include bleeding, vesicourethral anastomotic dehiscence, and anorectal injury, while late sequelae include urinary incontinence, anastomotic stenosis, urinary strictures and fistulas, osteomyelitis, and cancer recurrence. Radiation therapy can lead to bladder and bowel toxicity and, in rare cases, secondary malignancies. Imaging plays a crucial role in detecting and managing these complications. Multiphasic CT is preferred for detecting acute hemorrhage and urine leaks, while MRI is the modality of choice for evaluating urinary strictures, fistulas, and recurrent malignancies. Dynamic MR cystourethrography further enhances the assessment of urethral mobility and function, improves the detection of urinary fistula, and helps in surgical planning. MRI and PSMA PET imaging are key modalities for detecting post-treatment recurrence. As survival rates continue to improve for prostate cancer patients, the emphasis is shifting toward preserving quality of life and managing long-term treatment-related complications. In this review, we present a detailed overview of post-treatment surgical bed complications, emphasizing the role of various imaging modalities in the detection, characterization, and management of these complications.