Higher Preoperative Testosterone Linked to Faster Urinary Continence Recovery After Prostate Surgery

Men undergoing nerve-sparing surgery for prostate cancer may recover urinary control faster if their testosterone levels were higher before the operation, according to a retrospective study published in the European Journal of Medical Research. The difference between men with high and low testosterone was concentrated in the first six weeks after catheter removal, with no significant gap between the groups later in follow-up.

Researchers led by Shuai Liu, Guangbo Fu and Hesong Jiang analyzed records from 482 patients with clinically localized prostate cancer who underwent robot-assisted or laparoscopic nerve-sparing radical prostatectomy at a single tertiary center between January 2020 and December 2024. The team set out to examine whether preoperative serum testosterone, a potentially modifiable biochemical factor, was associated with the return of complete urinary continence, defined as using zero pads per day.

Recovery of continence after this type of surgery is largely predicted by factors that cannot be changed, such as a patient’s age and the length of the membranous urethra. Testosterone had remained an open question, and the authors used a landmark analysis, a statistical approach that separates early from later recovery, to characterize the timing of any association.

The primary outcome in the study was the time from catheter removal to the first documented complete continence recovery, with patients who did not recover censored at their last assessment and follow-up limited to 52 weeks. Testosterone was categorized as low when it was below 350 nanograms per deciliter and high when it was at or above that threshold. The analysis used Kaplan–Meier curves, log-rank tests and multivariable Cox regression, with week 6 serving as the landmark dividing early recovery from subsequent recovery.

Overall, 350 of the 482 patients achieved complete continence, while 132 were censored. Several established risk factors behaved as expected: patients older than 70 years had lower recovery rates than those 70 or younger, with a hazard ratio of 0.67 (95% confidence interval 0.54–0.83); unilateral rather than bilateral nerve sparing was associated with a hazard ratio of 0.66 (95% CI 0.53–0.82); and a prostate volume above 50 cubic centimeters carried a hazard ratio of 0.65 (95% CI 0.51–0.84). All of these comparisons reached a P value below 0.001.

Testosterone moved in the opposite direction. Men in the high-testosterone group had a higher recovery rate than men in the low-testosterone group, with a hazard ratio of 1.46 (95% CI 1.17–1.83; P < 0.001). In the landmark analysis, the high-testosterone group showed faster recovery during the first six weeks (P < 0.001), but among patients still without complete continence and still under follow-up at the six-week landmark, there was no significant between-group difference after week 6 (P = 0.65).

The authors conclude that higher preoperative testosterone was associated with faster continence recovery, with the difference between groups predominantly observed during the first six postoperative weeks. They are explicit that the findings should not be interpreted causally, citing the retrospective design and the fact that membranous urethral length, an important predictor of continence, was unavailable in their dataset.

As an observational, single-center study of men treated at one tertiary hospital, the analysis cannot establish that raising testosterone would improve continence outcomes. The cohort was limited to patients with clinically localized disease treated by nerve-sparing procedures, and the continence definition relied on pad usage as documented in routine records. The authors note that these limitations frame the work as hypothesis-generating rather than practice-changing.

Nevertheless, the researchers argue that the results justify prospective evaluation of perioperative testosterone optimization, including short-term testosterone replacement therapy in carefully selected men with confirmed low testosterone, as a strategy for improving early continence recovery. Because testosterone is potentially modifiable before surgery, unlike age or urethral anatomy, the finding points to a possible avenue for future interventional trials, while the current evidence remains associative and confined to the first weeks after catheter removal.

Subject of Research: The association between preoperative serum testosterone and early urinary continence recovery after nerve-sparing radical prostatectomy

Article Title: Preoperative serum testosterone and early urinary continence recovery after nerve-sparing radical prostatectomy: a landmark analysis

Article References: Liu, S., Fu, G., & Jiang, H. (2026). Preoperative serum testosterone and early urinary continence recovery after nerve-sparing radical prostatectomy: a landmark analysis. European Journal of Medical Research. https://doi.org/10.1186/s40001-026-05374-w

Image Credits: AI Generated

DOI: 10.1186/s40001-026-05374-w

Keywords: testosterone, radical prostatectomy, urinary continence, nerve-sparing surgery, prostate cancer, landmark analysis, Cox regression, retrospective study, catheter removal, surgical outcomes, Preoperative, serum