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Patient-focused care requires treatment that aligns with individual values and preferences. Although radical cystectomy (RC) combined with cisplatin-based neoadjuvant chemotherapy remains the standard worldwide treatment for muscle-invasive bladder cancer (MIBC), the procedure carries significant lifelong physical, emotional, and sexual consequences. As a result, both physicians and patient advocacy groups have pushed for effective bladder-sparing alternatives. To address this need, the International Bladder Cancer Group (IBCG) developed practical, expert-consensus guidance on bladder preservation therapies (BPTs), with an emphasis on identifying which patients are most suitable for these approaches.

A worldwide multidisciplinary panel comprising urologic oncologists, medical and radiation oncologists, pathologists, researchers, and patient advocates was convened to draft the recommendations. The team conducted comprehensive literature searches and applied a modified Delphi consensus method. Initial recommendations were circulated and voted on anonymously online, then debated during a face-to-face consensus meeting held August 25–26, 2023. Statements required at least 75% agreement to be accepted, and final wording was polished through subsequent virtual meetings and email correspondence.

General principles: Every patient newly diagnosed with MIBC should be assessed within a multidisciplinary team including urologic, medical, and radiation oncology specialists, along with pathology and radiology input to discuss bladder-preserving options. Pathology specimens should ideally be reviewed by a pathologist with specific expertise in urothelial carcinoma, since reinterpretation can alter management in roughly one-third of cases.

Trimodal therapy (TMT) as the leading alternative: TMT combining maximally complete transurethral resection, radiation therapy, and a concurrent radiosensitizing agent is the principal alternative to RC. The most suitable candidates are those with a single cT2 tumor, no hydronephrosis, no widespread carcinoma in situ (CIS), and adequate baseline bladder function. Although features such as cT3–4a disease, hydronephrosis, CIS, or variant histology indicate a less favorable prognosis, none are absolute exclusions. A large matched analysis demonstrated that TMT yields oncologic results comparable to RC, with 5-year metastasis-free and cancer-specific survival rates that did not differ significantly between groups.

TMT delivery details: Whenever feasible, the most thorough resection possible should be performed before therapy begins. Acceptable radiosensitizers include cisplatin, gemcitabine, 5-fluorouracil plus mitomycin C, or carbogen with nicotinamide. Induction chemotherapy is encouraged for higher-risk disease (cT3–4, hydronephrosis) and is strongly advised for node-positive cases. Hypofractionated radiation (55 Gy in 20 fractions) is endorsed as a standard option, while the value of including pelvic lymph nodes in the radiation field remains debated and should be decided individually.

Surveillance after TMT: Cross-sectional imaging is recommended every 3–6 months for the first 2–3 years, then annually for at least 5 years. Cystoscopy and urine cytology should occur every 3–4 months for the first 2 years, then every 6 months through year 5, with lifelong yearly cystoscopy strongly encouraged thereafter. Localized muscle-invasive recurrence warrants prompt salvage cystectomy in eligible patients.

Partial cystectomy (PC): PC is not a routine treatment and should be limited to highly selected cases primarily urachal adenocarcinoma or small, isolated tumors with clean margins and no concurrent CIS or variant histology. When used, neoadjuvant cisplatin-based chemotherapy follows the same indications as for RC, and standard bilateral pelvic lymph node dissection should accompany the procedure. Avoiding intra-operative tumor or urine spillage is essential.

Radical transurethral resection (TUR) alone: This is not standard practice and should be reserved for patients who refuse or cannot tolerate either RC or TMT. Ideal candidates have a small, solitary cT2 lesion without CIS, variant histology, or hydronephrosis. A second resection is advised, and the procedure must be carried out by a surgeon experienced in resecting deep into the peri-vesical fat without causing perforation.

Bladder preservation following systemic therapy: Forgoing surgery or radiation after a clinical complete response (cCR) to neoadjuvant chemotherapy or immunotherapy is still considered investigational. A rigorous cCR definition should include negative cystoscopy, cytology, biopsy, and cross-sectional imaging.

Biomarkers: Tissue, blood, and urine biomarkers (such as circulating tumor DNA and tumor genomic profiling) show promise but have not yet been validated for routine clinical use in selecting bladder-preservation candidates. Germline genetic testing should be considered for younger patients (under 50–55 years), those with relevant personal or family cancer history, or those with multifocal or upper tract urothelial disease.

Although no randomized trials have directly compared RC to BPTs, accumulated retrospective data suggest that carefully chosen patients can achieve comparable cancer outcomes with bladder preservation. The IBCG consensus offers clinicians and patients evidence-informed guidance on viable bladder-sparing alternatives until further data and biomarker advances refine selection criteria.

This multicenter study, conducted across five European referral hospitals, evaluated the surgical approach and outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion using the newer Hugo RAS robotic system. Researchers analyzed 29 patients treated between February 2023 and June 2024 making this the largest reported case series for this platform in bladder cancer surgery.

Most patients were male (72%), and the majority (68%) presented with muscle-invasive disease. Surgeons performed nerve-sparing procedures in four men and pelvic organ–preserving surgery in six women. For urinary reconstruction, 14 patients (48%) received an orthotopic neobladder, 11 (38%) had an ileal conduit, and four (14%) underwent ureterocutaneostomy.

The median operating time was 279 minutes, median blood loss was 250 ml, and patients stayed in hospital for a median of 7 days. Intraoperative complications occurred in four cases (14%), all classified as low grade. Within 90 days after surgery, 41% of patients developed complications of any severity, while only 10% experienced serious (high-grade) ones. The most frequent issues were urinary tract infections (31%), bowel paralysis or ileus (21%), and anemia needing transfusion (14%).

The authors concluded that the Hugo RAS system is a safe and practical option for performing RARC with intracorporeal diversion, producing results comparable to those of established robotic platforms — and importantly, without requiring any system-specific surgical adjustments. Limitations include the small sample size, the retrospective nature of the analysis, the involvement of only highly experienced surgeons (which may limit generalizability), and the absence of direct head-to-head comparison with other robotic systems.

Peyronie's disease (PD) is a chronic fibrotic disorder of the penis that causes curvature, pain, erectile dysfunction (ED), and psychological distress. Because evidence supporting treatment is often limited and clinical practice varies, this review compared four major international guidelines from the American Urological Association (AUA), European Association of Urology (EAU), Canadian Urological Association (CUA), and International Society for Sexual Medicine (ISSM) to highlight where they agree, where they diverge, and where research is still needed.

The authors conducted a structured literature search through June 2025, with two reviewers independently extracting recommendations across three areas: diagnosis, non-surgical treatment, and surgery. Guideline quality was assessed using the AGREE II tool.

Diagnosis: All four guidelines describe PD as a fibrotic condition with a biphasic course an active painful phase followed by a stable phase though they define "stability" slightly differently (ranging from 6 to 12 months of symptom duration). A detailed history, genital examination, and intracavernosal injection with goniometric curvature measurement are universally endorsed as standard before any invasive treatment. Validated tools such as the IIEF and PDQ help track symptoms, while MRI, CT, and X-ray are generally discouraged. All panels recognize the psychological burden and recommend considering mental health referral when distress is significant.

Non-surgical treatment: Oral therapies such as vitamin E, tamoxifen, and omega-3 fatty acids are not recommended due to lack of efficacy. NSAIDs may help with pain in the active phase, and PDE5 inhibitors can address coexisting ED. Extracorporeal shockwave therapy may relieve pain but does not correct curvature, and penile traction therapy shows modest promise but limited evidence. Among intralesional injections, collagenase clostridium histolyticum (CCH) has the strongest support though it is currently unavailable in Canada and the EU followed by interferon alpha-2b. Verapamil is accepted by the AUA, CUA, and ISSM but rejected by the EAU. Corticosteroids, hyaluronic acid, botulinum toxin-A, and platelet-rich plasma are generally discouraged outside clinical trials.

Surgical treatment: Surgery is reserved for stable disease with meaningful functional impairment. Tunical plication is preferred for milder curvature with preserved erectile function, while plaque incision or excision with grafting is recommended for severe (>60°) or complex deformities. Synthetic grafts are uniformly discouraged. Inflatable penile prosthesis implantation, often paired with straightening maneuvers, is the preferred option for men with refractory ED. The EAU specifically warns against the "sliding" technique due to the risk of glans necrosis. All panels stress the importance of detailed preoperative counseling, including realistic expectations about achieving a "functionally straight" rather than perfectly straight result.

The four guidelines broadly agree on PD biology and core principles but differ on definitions of disease stability and the acceptance of certain conservative therapies. These inconsistencies largely reflect differences in study quality, regulatory environments, and treatment availability rather than disagreement about the disease itself. The authors call for harmonized standards, standardized outcome measures, and multicenter research to strengthen the evidence base alongside continued investigation into the underlying fibrotic mechanisms of PD.

Benign prostatic hyperplasia (BPH) is one of the most common conditions affecting older men, with prevalence exceeding half of those over 50 and approaching four out of five men by age 80. It causes bothersome lower urinary tract symptoms and can lead to complications such as urinary retention and kidney impairment. Although BPH is increasingly understood as an age-driven disorder rooted in cellular senescence, chronic inflammation, immune dysregulation, and fibrotic tissue remodeling, the drugs available today still fall into just a handful of decades-old classes alpha-blockers, 5-alpha-reductase inhibitors, PDE5 inhibitors, antimuscarinics, and beta-3 agonists most of which only manage symptoms rather than altering the disease itself. The authors set out to map what has actually been happening in BPH drug pipelines over the past quarter century by analyzing trial registries directly, since published literature tends to capture only successful studies.

The investigators searched ClinicalTrials.gov and the Chinese Clinical Trial Registry (ChiCTR) for BPH-related drug trials registered between January 2000 and May 2025, cross-validated entries against the WHO ICTRP, and excluded non-pharmacological studies. After filtering, 224 trials remained for analysis. Two reviewers independently classified each trial by mechanism, symptom target, phase, sponsorship, and result-reporting status, with strong inter-rater agreement (kappa = 0.98). Statistical comparisons used chi-square, Fisher's exact, and t-tests, while Firth penalized logistic regression was applied to identify factors predicting whether trial results were ever publicly reported.

Trial landscape: Of the 224 included trials, roughly four out of five tested single agents, with combination regimens making up about a fifth and head-to-head comparisons almost nonexistent (just three trials). Industry sponsored most studies (71.9%), and registrations peaked between 2005 and 2016 before tapering off. Strikingly, only 55% of completed or otherwise non-ongoing trials had publicly available results.

Mechanism and outcomes: Among the 211 non-ongoing trials, only 43 targeted prostate volume reduction and of those reporting results, fewer than half showed meaningful shrinkage. By contrast, 137 trials focused on symptom relief independent of volume, with about three-quarters of disclosed studies reporting success. The dominant endpoint was the IPSS symptom score (used in over half of trials), while structural measures such as prostate volume appeared in fewer than 5%.

Mechanism distribution by phase: Established drug classes monopolized late-stage development alpha-1 antagonists and 5-alpha-reductase inhibitors made up the bulk of Phase III/IV studies while novel approaches such as immune modulation, apoptosis induction, cytotoxic agents, and neurotoxins were largely confined to early-phase research and have produced no approved drugs to date.

Promising candidates: The authors highlighted six investigational therapies with translational potential: vibegron (a beta-3 agonist showing significant improvements in storage symptoms), topsalysin (a prostate-targeted cytotoxin), NX-1207 (an apoptosis inducer with mixed late-phase results), talaporfin sodium (a photodynamic agent), GV1001 (an immunomodulatory peptide with positive Phase II and III data), and a pyridostigmine-plus-silodosin combination that improved catheter-removal success.

Predictors of result disclosure: Industry sponsorship was the strongest predictor of whether results were reported (odds ratio 6.67), and drug mechanism class was also significantly associated with disclosure overall. Sample size and enrollment ratio generally were not predictive, although enrollment ratio did matter in Phase II.

The authors describe BPH drug development as caught in a structural "innovation trap": investment continues to flow toward symptom-management drugs with established commercial pathways, while disease-modifying approaches that target the underlying biology of prostatic aging fibrosis, senescence, chronic inflammation remain underdeveloped. Compounding the problem, nearly half of completed trials never publicly disclose their results, obscuring the true rate of failure and limiting what the field can learn from past efforts. The authors call for three shifts: prioritizing mechanisms with genuine disease-modifying potential and using structural endpoints like prostate volume, designing trials with longer follow-up and composite outcomes suited to BPH's slow course, and improving transparency through better reporting practices and stronger public investment.

Imagine the symbolism of a wedding ring slipped onto the most unexpected place on the body not as a romantic gesture, but as an act of heartbreak. That's exactly the bizarre and harrowing scenario described in this remarkable case report, where a cancelled marriage set off a chain of events that ended with surgeons wielding industrial metal-cutting tools in a desperate race to save a man's penis.

A 38-year-old man arrived at the emergency department in agony, with a swollen, discolored penis. The story he reluctantly shared was both tragic and unusual: after his engagement was abruptly called off, he had in a moment of emotional turmoil slipped his engagement ring around the base of his penis. He then drowned his sorrows in alcohol and fell asleep, completely forgetting about it. By the time he woke up roughly a day later, the ring had become a vice. Embarrassment kept him from seeking help, and his frantic do-it-yourself attempts only made things worse.

On examination, a stainless-steel ring (1 cm wide, 2 mm thick) had clamped down hard at the base of his penis. The shaft beyond the ring was massively swollen, engorged, and turning a worrying shade of cyanotic blue clear signs that blood was being trapped and tissue was beginning to suffocate. Without intervention, the trajectory was grim: ischemia, gangrene, and potentially even auto-amputation.

Here's where the case becomes almost cinematic. Under general anesthesia, the team first tried to relieve the pressure by making a circumcoronal incision and using needle punctures to drain the trapped fluid a maneuver that successfully shrank the swollen tissue but left the unyielding ring stubbornly in place.

What followed was an escalating battle of instruments versus metal:

Even then, the drama wasn't over. The cut ends of the ring refused to spring open. The team had to deploy two bone cutters simultaneously, prying the ring apart laterally until it released its grip. Almost immediately after liberation, the cyanotic blue color faded and healthy circulation returned.

Remarkably, despite everything, the patient walked away with only superficial skin abrasions no necrosis, no permanent damage. He received psychiatric evaluation, was started on antidepressants, and underwent psychosexual counseling to address the emotional triggers behind the incident. At his three-month follow-up, his erectile function score (IIEF) was a healthy 23, urination was normal, and sexual function was preserved. A storybook recovery from a decidedly un-storybook situation.

Penile strangulation by metallic objects is a rare but genuine urological emergency, and there is no standardized protocol. The authors emphasize three lessons: act fast to relieve distal swelling, escalate cutting tools methodically when soft instruments fail, and always place protective shielding (a tongue depressor, laryngoscope blade, or PVC plate) between the metal and the penile skin to prevent thermal or mechanical injury during cutting. They also stress that psychological evaluation should be a routine part of follow-up because behind these cases there is often a story worth listening to.

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