It's Saturday morning time for your PSA Weekly. This week, we're bringing you a particularly interesting topic that may directly affect your practice, introducing a new approach you can incorporate during common general surgery procedures.

If you find this issue valuable, please consider referring your colleagues to PSAWeekly.com so they can join our growing community of urologists and never miss a brief.

Your feedback is highly appreciated as well don't hesitate to drop us an email at [email protected] with your thoughts, suggestions, or topics you'd like us to cover. Grab your coffee, settle in, and let's dive into this week's brief.

In a prespecified analysis of the international, multicenter, placebo-controlled POISE-3 randomized trial, Tikkinen and colleagues evaluated the efficacy and safety of intraoperative tranexamic acid (TXA; two 1 g intravenous boluses administered at the start and end of surgery) among 1124 adults (≥45 years) with elevated bleeding and cardiovascular risk undergoing urologic procedures, including robotic and open radical prostatectomy, laparoscopic and robotic partial nephrectomy, laparoscopic and open radical nephrectomy, transurethral resection of the prostate (TURP)/transurethral surgery for benign prostatic obstruction, percutaneous nephrolithotomy (PCNL), open radical cystectomy, transurethral resection of bladder tumor (TURBT), female pelvic floor surgery, and pyeloplasty, across open, laparoscopic/robotic, transurethral, and percutaneous approaches.

At 30 days, the composite bleeding outcome (life-threatening, major, or critical-organ bleeding) occurred in 8.1% of TXA recipients versus 10.9% of those receiving placebo (HR 0.73, 95% CI 0.50–1.07), with a statistically significant reduction in major bleeding (6.1% vs 9.5%; HR 0.63, 95% CI 0.41–0.97) and in ISTH major bleeding (HR 0.52, 95% CI 0.33–0.81); transfusion rates trended lower with TXA (8.6% vs 11%).

The composite thrombotic safety outcome comprising myocardial injury after noncardiac surgery (MINS), nonhemorrhagic stroke, peripheral arterial thrombosis, and symptomatic proximal venous thromboembolism (VTE) was comparable between groups (12.1% vs 10.9%; HR 1.12, 95% CI 0.79–1.58), with stroke (0.4%) and VTE (0.5%) events rare and balanced across arms, and no significant interactions identified by surgical approach, cancer status, or recent antithrombotic exposure.

The authors conclude that perioperative TXA is a reasonable, low-cost intervention for mitigating major bleeding in urologic surgery particularly among patients at heightened bleeding risk without evidence of a clinically meaningful increase in thrombotic complications, thereby supporting its broader consideration in urologic guidelines and perioperative pathways.

The 2026 European Association of Urology (EAU) Guidelines on the management of non-neurogenic male lower urinary tract symptoms (MLUTS), developed by a multidisciplinary expert panel, provide an updated evidence-based framework derived from a structured literature review of Medline, EMBASE, and the Cochrane Library covering May 2023 to May 2025. The guidelines adopt a symptom-focused perspective that treats the lower urinary tract as a functional whole rather than concentrating solely on prostatic disease, and clearly distinguish benign prostatic hyperplasia (histological), benign prostatic enlargement (anatomical), and benign prostatic obstruction (functional). Diagnostic evaluation emphasizes thorough history-taking, validated symptom questionnaires (e.g., IPSS, ICIQ-MLUTS), bladder diaries of at least three days, physical examination including digital rectal exam, urinalysis, selective PSA testing, uroflowmetry, post-void residual measurement, and judicious use of imaging, cystoscopy, and urodynamics when findings are likely to alter management.

Management is stratified by symptom severity and risk of progression, beginning with watchful waiting and lifestyle modification, progressing to pharmacological options such as α1-blockers, 5α-reductase inhibitors, muscarinic antagonists, β3-agonists, PDE5 inhibitors, phytotherapy, or combination regimens, and culminating in surgical interventions including TURP, anatomical endoscopic enucleation (HoLEP, ThuLEP, bipolar), laser vaporization, Aquablation, prostatic urethral lift, and prostatic artery embolization tailored to prostate size, comorbidities, anticoagulation status, and patient priorities like ejaculatory preservation.

Notably, this edition introduces a dedicated chapter on voiding dysfunction in men under 40, addressing primary bladder neck obstruction and dysfunctional voiding (diagnosed ideally with video-urodynamics and treated with α-blockers, behavioral therapy with biofeedback, or bladder neck incision/intermittent catheterization when refractory), and incorporates prior recommendations on underactive bladder, ultimately reinforcing that patient-centered, shared decision-making should balance symptom relief, sexual function, and durability of outcomes.

Obesity introduces additional technical complexity to adrenalectomy, and although robotic adrenalectomy (RA) is thought to provide certain benefits over laparoscopic adrenalectomy (LA), evidence specifically addressing obese patients has been sparse.

This systematic review and meta-analysis pooled data from eight retrospective cohort studies encompassing 1,107 obese patients to compare perioperative outcomes between RA and LA, with additional subgroup analyses examining body habitus (obese vs. non-obese) and surgical route (lateral trans-abdominal [LT] vs. posterior retroperitoneal [PR]). Study quality was appraised using the Newcastle–Ottawa Scale, and certainty of evidence was graded with the GRADE framework. Compared with LA, RA was associated with significantly lower estimated blood loss (mean difference −36 mL; p < 0.001) and a shorter length of hospital stay (mean difference −1.22 days; p < 0.001), while operative time, complication rates, conversion to open surgery, and mortality did not differ meaningfully between the two techniques.

Subgroup analyses showed that non-obese patients undergoing LA had a slightly shorter hospital stay than their obese counterparts (p = 0.03), whereas pooled robotic data revealed no such obesity-related difference. When surgical approaches were compared, the PR route yielded lower blood loss in laparoscopic cases and a shorter hospital stay overall (p = 0.001) relative to the LT route, with no differences in operative time, complications, or conversions.

The authors concluded that RA offers clear perioperative advantages particularly reduced blood loss and faster discharge without compromising safety in obese patients, though they emphasized that the retrospective nature of the included studies, heterogeneity in BMI severity, and lack of long-term outcome data warrant confirmation through prospective, high-quality trials.

This systematic review and meta-analysis aimed to quantify the incidence of bladder neck contracture (BNC) following surgical treatment of benign prostatic hyperplasia (BPH). The authors searched PubMed, Embase, and CENTRAL through October 29, 2024, for randomized prospective trials comparing two surgical techniques in adult patients with at least two years of follow-up, pooling proportions and risk ratios using random-effects models.

Eleven studies including 1,536 patients were analyzed, showing an overall pooled BNC incidence of 3% (95% CI 2–5), with rates of 9% (95% CI 4–15) for photoselective vaporization of the prostate (PVP), 3% (95% CI 2–5) for transurethral resection of the prostate (TURP), and 3% (95% CI 1–5) for holmium laser enucleation of the prostate (HoLEP).

Neither TURP nor HoLEP was associated with a significantly increased risk of BNC compared to alternative approaches (including transurethral incision of the prostate, thulium laser resection, diode laser vaporization, laparoscopic simple prostatectomy, open prostatectomy, and bipolar enucleation), with log risk ratios of 0.19 (95% CI −0.70 to 1.08) and −0.34 (95% CI −1.41 to 0.73), respectively.

Smaller prostate size and anticoagulant use were identified as potential risk factors, and the most commonly preferred management for established BNC was bladder neck or prostate incision, or re-resection. Overall, BNC is an uncommon complication after BPH surgery, with HoLEP and TURP carrying risks comparable to other surgical options, though further research is needed to clarify modifiable risk factors and evaluate emerging therapies.

58-year-old man is referred to a minimally invasive urologic surgeon for evaluation of a 4.5 cm enhancing right renal mass incidentally found on CT imaging during a workup for abdominal pain. His past medical history is significant for hypertension, type 2 diabetes mellitus, and obstructive sleep apnea on CPAP. His BMI is 41 kg/m². Vital signs are within normal limits. Physical examination reveals a centrally obese abdomen without palpable masses or tenderness. Laboratory studies show a serum creatinine of 1.1 mg/dL and otherwise unremarkable metabolic and hematologic panels. Staging workup demonstrates no evidence of metastatic disease. The patient inquires about whether a minimally invasive approach is appropriate given his body habitus.

Compared with the open approach, which of the following minimally invasive urologic procedures has demonstrated the most significant superior perioperative outcomes (estimated blood loss, time to resumption of oral intake, ambulation, narcotic requirement, and length of hospital stay) in obese patients?

A. Robotic/laparoscopic radical nephrectomy
B. Robotic-assisted laparoscopic radical prostatectomy
C. Robotic-assisted radical cystectomy with ileal conduit urinary diversion
D. Robotic-assisted radical cystectomy with orthotopic neobladder reconstruction

A 62-year-old man presents to the urology clinic for his first visit, referred by his primary care physician for evaluation of lower urinary tract symptoms (LUTS). He reports a 1-year history of weak urinary stream, hesitancy, nocturia (3 times per night), and a sensation of incomplete bladder emptying. His past medical history is notable for well-controlled hypertension and dyslipidemia. He takes amlodipine and atorvastatin. He denies hematuria, dysuria, fever, or flank pain. On physical examination, his abdomen is soft and non-tender with no palpable bladder. Digital rectal examination reveals a smooth, symmetrically enlarged, non-tender prostate without nodules. Urinalysis is unremarkable. You are considering further investigations as part of his workup.

Which of the following statements regarding estimated glomerular filtration rate (eGFR) in the evaluation of male LUTS is correct?

A. Based on the AUA guideline (2021), all patients presenting with LUTS should have an eGFR measured at initial evaluation.
B. Based on the EAU guideline, there is no recommendation for testing serum creatinine or eGFR in the evaluation of male LUTS.
C. Approximately 35% of patients presenting with LUTS receive a diagnosis of chronic kidney disease.
D. Based on the Medical Therapy of Prostate Symptoms (MTOPS) trial, fewer than 1% of patients with LUTS experienced renal insufficiency/kidney failure over the follow-up period.
E. The International Prostate Symptom Score (IPSS) is highly correlated with eGFR in middle-aged men with moderate-to-severe LUTS.

[email protected]