Welcome back to your Saturday PSAWeekly.

This week we're comparing the conventional against the alternative across every subspecialty: retropubic versus standard TOT slings, hot versus cold knife ablation, and AI- or PET-guided pathways challenging what we've long called "standard" diagnostic practice. One thread throughout: when we actually put technique against technique, does the established approach still win?

This week's issue covers:

Let's get into it.

Background: Stress urinary incontinence affects 20–30% of women and frequently impairs sexual function, contributing to anxiety, shame, and reduced self-esteem. Mid-urethral sling surgery is the gold standard treatment, but its effects on sexual outcomes particularly dyspareunia remain inconsistent across the literature. The retropubic TOT (TOTRP) is a modified transobturator technique designed to reduce complications associated with conventional TOT, including vaginal erosion and nerve injury, through a deeper, more retropubically-oriented tape trajectory.

Methods: This retrospective study included 108 sexually active women who underwent either conventional TOT (n=54) or TOTRP (n=54) between 2023 and 2025. Sexual function was assessed using the validated 6-item Female Sexual Function Index (FSFI-6) preoperatively and at six months postoperatively.

Results: Both groups showed significantly improved overall FSFI scores after surgery, with no significant difference in total scores between the two techniques. However, when individual domains were examined, only the TOTRP group demonstrated a significant improvement in dyspareunia scores at six months. No meaningful change in dyspareunia was seen in the conventional TOT group. Coital incontinence decreased significantly in both groups postoperatively. Two minor complications occurred in the conventional TOT group; none were recorded in the TOTRP group.

Discussion: The improvement in dyspareunia observed in the TOTRP group may reflect anatomical differences in tape trajectory specifically, the more cranially positioned incision and more upward sling angle, which may reduce mechanical stress on periurethral tissues and better preserve the functional relationship between the clitoral complex and the anterior vaginal wall. However, the authors caution that direct superiority of TOTRP over conventional TOT cannot be formally concluded, as between-group differences in dyspareunia were not statistically compared. The retrospective, non-randomized design and the chronological transition from one technique to the other within the study period may have introduced learning-curve and selection biases.

Limitations: Retrospective design, lack of randomization, single-surgeon experience, higher menopause rate in the TOTRP group as a potential baseline imbalance, short follow-up, and use of the abbreviated rather than full FSFI questionnaire.

Conclusion: Both conventional TOT and TOTRP provide comparable overall improvements in female sexual function after stress urinary incontinence surgery. The TOTRP technique may offer an advantage specifically in reducing dyspareunia, though this remains to be confirmed in prospective randomized trials with longer follow-up.

Background: Mirabegron, a beta-3 adrenergic agonist, received US approval in 2021 for pediatric use in children over 3 years old. Its use in younger children with neurogenic bladder secondary to spina bifida remains off-label. This study examined its safety, tolerability, and urodynamic impact in this younger age group.

Methods: A retrospective single-center review of spina bifida patients under 3 years old treated with mirabegron. Patients were divided into three groups: those receiving mirabegron as primary therapy, those switched from antimuscarinics due to intolerable side effects, and those using it as an add-on alongside antimuscarinics.

Results: Nineteen patients received mirabegron at a median age of 24 months. Bladder compliance improved in all but one patient. Bladder capacity increased in those on primary or combination therapy and was maintained in those who switched from antimuscarinics. All ten patients who changed from antimuscarinics to mirabegron reported complete resolution of the side effects that had prompted the switch. No patient discontinued mirabegron due to adverse effects.

Conclusion: Off-label mirabegron use in children under 3 with neurogenic bladder from spina bifida appears safe and beneficial particularly as an alternative for those who cannot tolerate antimuscarinics. Larger prospective studies are needed to confirm these findings.

Background: Posterior urethral valves (PUV) are the most common cause of congenital lower urinary tract obstruction in boys. Despite early surgical treatment, a significant proportion develop chronic or end-stage kidney disease. Endoscopic valve ablation is standard, but whether cold or hot knife techniques yield superior results in a single session remains unresolved.

Methods: A PROSPERO-registered systematic review following PRISMA 2020 guidelines searched PubMed and Embase through December 2025 for studies comparing cold and hot ablation techniques in children under 18 undergoing primary PUV ablation, with at least 6 months of follow-up and postoperative imaging confirmation.

Results: Twenty-six studies encompassing 1,725 patients were included; one randomized trial, five prospective, and twenty retrospective studies. Cold techniques were used in 829 patients (mainly cold knife), and hot techniques in 896 (mainly electrofulguration and Bugbee electrode). Single-session success rates were highly variable: 22–100% for cold techniques and 71–100% for hot techniques. Reintervention for residual valves ranged from 0–78% in cold cases versus 0–28.6% in hot cases. Urethral stricture rates ranged from 0–11% after cold procedures and 0–24% after hot ones. Significant heterogeneity across studies precluded formal statistical pooling.

Conclusion: Both approaches achieve acceptable success and complication rates. Cold ablation appeared marginally safer in terms of urethral stricture risk, though this must be interpreted cautiously given the predominantly observational and heterogeneous nature of the available evidence. Well-designed prospective trials are needed.

This multicenter study developed PelviX3Net, a UNet++/EfficientNetV2-L-based semantic segmentation model designed to help surgeons identify key anatomical structures during pelvic lymph node dissection (PLND) a technically demanding step in colorectal, gynecological, and urological cancer surgery due to the proximity of the ureter, obturator nerve, and iliac vessels.

The model was trained on nearly 24,000 annotated images drawn from 293 PLND procedures across three surgical specialties. On three-fold cross-validation, it achieved Dice similarity coefficients ranging from 0.65 (ureter) to 0.87 (external iliac vein), with the ureter proving hardest to segment despite high specificity.

To test clinical value, 36 surgeons of varying specialty and seniority reviewed hundreds of 0.5-second video snippets from real PLND cases, identifying target structures with and without AI-generated overlay assistance. AI assistance significantly improved both sensitivity and specificity for all four structures (p<.001), with particularly notable specificity gains among trainees suggesting the tool reduced misidentification rather than introducing false alarms.

The authors note key limitations: testing used isolated, context-free video snippets rather than continuous real-world surgery; ureter recognition still needs improvement before clinical deployment; only four structures are currently covered; and all data originated from Japanese institutions, limiting generalizability. They conclude the model shows promise as an assistive (not autonomous) navigation tool, with real intraoperative validation still needed.

The PRIMARY2 trial is a multicentre, phase 3, non-inferiority randomised controlled trial conducted across seven Australian hospitals, addressing a common clinical dilemma: men with high clinical risk for prostate cancer but non-suspicious or equivocal MRI findings (PI-RADS 2 or 3), who currently still proceed to biopsy despite a low probability of significant disease.

Investigators randomised 660 biopsy-naive men 1:1 to either standard systematic transperineal biopsy (control) or [⁶⁸Ga]Ga-PSMA-11 PET-CT (experimental), with the latter group undergoing biopsy only if PET-CT was positive (PRIMARY score 3–5), while negative scans led to PSA surveillance instead.

Key findings: detection of clinically significant cancer (Gleason ≥3+4) was statistically non-inferior between groups (12% with PET-CT vs 16% with standard biopsy). Critically, PSMA PET-CT allowed nearly half of the experimental group (49%) to avoid biopsy altogether, and cut diagnosis of clinically insignificant cancer roughly in half (14% vs 32%). Biopsy-related complications (pain, bleeding, erectile dysfunction) were similar between groups.

The authors conclude this is the first randomised evidence supporting PSMA PET-CT as a triage tool in this specific population, potentially sparing large numbers of men unnecessary biopsies without missing dangerous cancers. They note limitations including the Australian-only cohort, unresolved cost-effectiveness questions, and the need for validation with other PSMA tracers before widespread practice change.

This cross-sectional study examined how benign prostatic hyperplasia symptom severity relates to aging male symptoms, and whether perceived partner responsiveness explains this connection. Researchers surveyed 412 men aged 50 and older with confirmed BPH across multiple hospitals in Hangzhou, China, using validated scales for BPH symptoms, aging male symptoms, and perceived partner responsiveness, then analyzed the data using structural equation modeling and mediation analysis.

Greater BPH symptom severity was clearly linked to worse aging male symptoms overall. Interestingly, perceived partner responsiveness only became relevant at higher symptom severity: men with moderate BPH symptoms showed no association between symptom burden and how supported they felt by their partner, whereas men with severe symptoms did show this link. The authors suggest this happens because moderate symptoms are usually managed independently through behavioral adjustments, while severe symptoms push men toward greater reliance on their partners for emotional and practical support.

When testing whether partner responsiveness explained the connection between BPH severity and aging symptoms, the results showed no mediating effect at moderate symptom levels, and only a small, partial mediating effect at severe symptom levels meaning most of the impact of BPH symptoms on aging-related complaints came through direct physiological pathways rather than relationship dynamics.

The authors conclude that treating urinary symptoms directly should remain the top clinical priority for aging men with BPH, while supportive partner relationships may offer a modest, complementary benefit primarily for those with more severe symptoms. They note limitations including the cross-sectional design (which can't establish causality), reliance on self-report data, single-region sampling, and the fact that only patients' own perceptions of their partners were measured rather than partners' actual behavior.

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