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Introduction: This systematic review addressed the length of hospital stay (LOS) and procedure time in patients with small renal masses (SRM) undergoing open, conventional laparoscopic (OPN), and robot-assisted partial nephrectomy (RAPN), as well as percutaneous thermal ablation (PTA) in different geographic areas., Methods: We conducted a comprehensive search in databases (MEDLINE, EMBASE, CINAHL) until July 2023, and we applied random-effect meta-analysis, with evidence certainty assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework., Results: We screened 3456 titles and abstracts, ultimately identifying 60 eligible studies. For the length of LOS (days) following OPN, our pooled estimates revealed means of 5.7 in North America, 7.1 in Europe, and 13.4 in Asia; following laparoscopic partial nephrectomy, means were 3.1, 5.4, and 5.8, respectively; for RAPN, means were 2.7, 3.8, and 7.1; and for PTA, means were 1.2, 1.6, and 1.6. Regarding procedure time (minutes) after OPN, means were 187 in North America, 132 in Europe, and 184 in Asia; after laparoscopic partial nephrectomy, means were 198, 127, and 200; after RAPN, means were 189, 150, and 192; and for PTA, mean was 144 in North America and no studies addressed procedure time in Europe and Asia., Conclusions: Our study provides the most trustworthy available estimates of LOS and procedure time for patients undergoing invasive procedures for the management of SRM. These findings have emphasized the need for context-specific considerations when informing patients and making treatment decisions.

Introduction: Several recent randomized trials evaluated the impact of adjuvant immune checkpoint inhibitor (ICI)-based therapy on post-surgical outcomes in renal cell carcinoma (RCC), with disparate results. The objective of this consensus statement is to provide data-driven guidance regarding the use of ICIs after complete resection of clear-cell RCC in a Canadian context., Methods: An expert panel of genitourinary medical oncologists, urologic oncologists, and radiation oncologists with expertise in RCC management was convened in a dedicated session during the 2022 Canadian Kidney Cancer Forum in Toronto, Canada. Topic statements on the management of patients after surgery for RCC, including counselling, risk stratification, indications for medical oncology referral, appropriate followup, eligibility and management for adjuvant ICIs, as well as treatment options for patients with recurrence who received adjuvant immunotherapy, were discussed. Participants were asked to vote if they agreed or disagreed with each statement. Consensus was achieved if greater than 75% of participants agreed with the topic statement., Results: A total of 22 RCC experts voted on 14 statements. Consensus was achieved on all topic statements. The panel felt patients with clear-cell RCC at increased risk of recurrence after surgery, as per the Keynote-564 group definitions, should be counselled about recurrence risk by a urologist, should be informed about the potential role of adjuvant ICI systemic therapy, and be offered referral to discuss risks and benefits with a medical oncologist. The panel felt that one year of pembrolizumab is currently the only regimen that should be considered if adjuvant therapy is selected. Panelists emphasized current opinions are based on disease-free survival given the available results. Significant uncertainty regarding the benefit and harms of adjuvant therapy remains, primarily due to a lack of consistent benefit observed across similar trials of adjuvant ICI-based therapies and immature overall survival (OS) data., Conclusions: This consensus document provides guidance from Canadian RCC experts regarding the potential role of ICI-based adjuvant systemic therapy after surgery. This rapidly evolving field requires frequent evidence-based re-evaluation.

Introduction: Robot-assisted surgery (RAS) has a positive impact on the quality of care given to patients. Its increasing adoption in Canadian urology practice also influences the surgical training of residents and fellows. Currently, the lack of clear objectives makes RAS education challenging. The main objective of our study was to highlight how urology trainees perceive the importance of RAS and the standardization of its training., Methods: In 2021, we conducted a survey of all the residents and fellows enrolled in a Canadian urology program. The questions assessed their opinion on the importance of RAS and on their robotic surgery training., Results: The response rate was 29%. The majority of participants (67%) wished they would have a better exposure to RAS during their surgical training. Only 7% of respondents reported that their program had clear criteria to help them progress through the steps of RAS, and most trainees (81%) felt their residency program should provide them with a formal RAS training program. Seventy-six percent of respondents believed that RAS would become a core skill required by the Royal College in the future, although 32% feared it would hinder their ability to learn other important techniques, such as open surgery., Conclusions: Our study revealed that although most respondents are interested in RAS, their training lacks standardization. Moreover, the potential integration of RAS as a core skill of the Royal College faces some important challenges, mostly due to the perceived lack of time to learn a new surgical technique.

Introduction: Shared decision-making incorporates patients' values and preferences to achieve high-quality decisions. The objective of this study was to develop an acceptable patient decision aid to facilitate shared decision-making for the management of small renal masses (SRMs)., Methods: The International Patient Decision Aids Standards were used to guide an evidence-based development process. Management options included active surveillance, thermal ablation, partial nephrectomy, and radical nephrectomy. A literature review was performed to provide incidence rates for outcomes of each option. Once a prototype was complete, alpha-testing was performed using a 10-question survey to assess acceptability with patients, patient advocates, urologists, and methodological experts. The primary outcome was acceptability of the decision aid., Results: A novel patient decision aid was created to facilitate shared decision-making for the management of SRMs. Acceptability testing was performed with 20 patients, 10 urologists, two patient advocates, and one methodological expert. Responders indicated the decision aid was appropriate in length (82%, 27/33), well-balanced (82%, 27/33), and had language that was easy to follow (94%, 31/33). All patient responders felt the decision aid would have been helpful during their consultation and would recommend the decision aid for future patients (100%, 20/20). Most urologists reported they intend to use the decision aid (90%, 9/10)., Conclusions: A novel patient decision aid was created to facilitate shared decision-making for management of SRMs. This clinical tool was acceptable with patients, patient advocates, and urologists and is freely available at: https://decisionaid.ohri.ca/decaids.html.

Introduction: Adequate knowledge of biostatistics is essential for healthcare providers to stay up to date with medical advances and maintain an evidence-based practice. However, training in clinical research in Canadian residency programs varies considerably. Our study aimed to determine Canadian urology trainees' knowledge of biostatistics and interpretation of the scientific literature., Methods: We conducted a national survey of all Canadian urology residents and fellows, which assessed experiences with biostatistics, self-reported confidence with statistical questions, and knowledge of biostatistical concepts., Results: Out of 201 urology trainees, 74 (36.8%) responded to the survey. The majority of respondents disagreed or strongly disagreed with the fact that they had sufficient training in biostatistics in medical school (67.6%) or that their current knowledge was sufficient for the rest of their career (66.1%). If given the chance, 82.3% of respondents would like to learn more about biostatistics. About half of respondents were able to correctly identify ordinal variables (51.5%), discrete variables (52.9%), or interpret adjusted odds ratios (50.0%). Despite senior residents reporting more confidence on biostatistical questions, our results did not demonstrate significant differences in overall knowledge according to level of training or experience with biostatistics., Conclusions: Our results identified important knowledge gaps among current Canadian urology trainees. Most trainees do not believe they have sufficient training in biostatistics. Knowledge of basic statistical concepts was lower than expected and did not significantly differ according to level of training. Our results highlight the need for structured, dedicated training in biostatistics for urology trainees within the new Competence by Design teaching framework.

Introduction: The Canadian Kidney Cancer information system (CKCis) has prospectively collected data on patients with renal tumors since January 1, 2011 from 16 sites within 14 academic centers in six provinces. Canadian kidney cancer experts have used CKCis data to address several research questions. The goal of this study was to determine if the CKCis cohort is representative of the entire Canadian kidney cancer population, specifically regarding demographic and geographic distributions., Methods: The CKCis prospective cohort was analyzed up to December 31, 2018. Baseline demographics and tumor characteristics were analyzed, including location of patients' residence at the time of CKCis entry. Geographic data is presented by province, rural vs. urban via postal code information (2 nd digit=0) and by Canadian urban boundary files. To determine the proportion of renal cell carcinoma (RCC) patients that CKCis captures, CKCis accruals were compared to projected Canadian Cancer Society RCC incidence in 2016-2017 and the incidence from the 2016 Canadian Cancer Registry. To determine if the CKCis baseline data is representative, it was compared to registry data and other published data when registry data was not available., Results: This CKCis cohort includes 10 298 eligible patients: 66.6% male, median age 62.6 years; 14.6% had metastatic disease at the time of diagnosis and 70.4% had clear-cell carcinomas. The CKCis cohort captures about 1250 patients per year, which represents approximately 20% of the total kidney cancer incidence. The proportion of patients captured per province did vary from 13-43%. Rural patients make up 17% of patients, with some baseline differences between rural and urban patients. There appears to be no major differences between CKCis patient demographics and disease characteristics compared to national data sources. Canadian heat maps detailing patient location are presented., Conclusions: CKCis contains prospective data on >10 000 Canadian kidney cancer patients, making it a valuable resource for kidney cancer research. The baseline demographic and geographic data do appear to include a broad cross-section of patients and seem to be highly representative of the Canadian kidney cancer population. Moving forward, future projects will include determining if CKCis cancer outcomes are also representative of the entire Canadian kidney cancer population and studying variations across provinces and within rural vs. urban areas.

Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes., Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting., Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles)., Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Introduction: Active surveillance (AS) is an accepted management strategy for low-risk prostate cancer (PCa), but its role in the management of favorable intermediate-risk PCa remains controversial. Most reports studying the role of AS for these men generally lack long-term followup and include small numbers of patients. Our objective was to report the outcomes of men diagnosed with Gleason grade groups (GGG) 2 and 3 PCa who were managed expectantly., Methods: Using administrative datasets and pathology reports, we identified all men who were diagnosed with GGG 2 and 3 PCa and managed expectantly between 2002 and 2011 in Ontario, Canada. Outcomes and associated factors were estimated using cumulative incidence function methods and multivariable Cox regression models, respectively., Results: We identified 926 men who were managed expectantly (AS [n=374] or watchful waiting [n=552]). The eight-year cancer-specific survival was 94% and 89% for the AS and watchful waiting cohorts, respectively. Among AS men, 266 (71%) received treatment after a followup of approximately eight years. Cumulative AS discontinuation rates at one and five years were 30.5% and 65.1%, respectively., Conclusions: Expectant management of GGG 2 and 3 PCa may be an option for certain men. Notably for AS patients, the cancer-specific mortality at eight years was 6%, and over 65% of men underwent treatment within five years. Further studies are required to evaluate which patients, based on disease-specific features and competing health risks, would benefit most from a conservative strategy.

Introduction: Renal tumour biopsies (RTBs) can provide the histology of small renal masses (SRMs) prior to treatment decision-making. However, many urologists are reluctant to use RTB as a standard of care. This study characterizes the current use of RTB in the management of SRMs and identifies barriers to a more widespread adoption., Methods: A web-based survey was sent to members of the Canadian and Quebec Urological Associations who had registered email address (n=767) in June 2016. The survey examined physicians' practice patterns, RTB use, and potential barriers to RTB. Chi-squared tests were used to assess for differences between respondents., Results: The response rate was 29% (n=223), of which 188 respondents were eligible. A minority of respondents (12%) perform RTB in >75% of cases, while 53% never perform or perform RTB in <25% of cases. Respondents with urological oncology fellowship training were more likely to request a biopsy than their colleagues without such training. The most frequent management-related reason for not using routine RTB was a belief that biopsy won't alter management, while the most frequent pathology-related reason was the risk of obtaining a false-negative or a non-diagnostic biopsy., Conclusions: Adoption of RTBs remains low in Canada. Concerns about the accuracy of RTB and its ability to change clinical practice are the largest barriers to adoption. A knowledge translation strategy is needed to address these concerns. Future studies are also required in order to define where RTB is most valuable and how to best to implement it.

Introduction: Non-muscle-invasive bladder cancer (NMIBC) accounts for 75-85% of all urothelial bladder cancers (UBC). Many UBC patients are also afflicted by diabetes mellitus (DM). It has been postulated that several oral hypoglycemic agents could impact disease-specific survival (DSS), but the data are sparse among NMIBC patients. Our primary objective was to evaluate the impact of metformin on DSS and overall survival (OS) in NMIBC patients., Methods: This is a retrospective, population-based study that used linked administrative databases to identify diabetic patients ≥66 years who were subsequently diagnosed with NMIBC in Ontario between 1992 and 2012. Cumulative use of metformin and other hypoglycemic agent were calculated before and after NMIBC diagnosis. DSS and OS were estimated using multivariable competing risk and Cox proportional hazards models, respectively., Results: A total of 1742 subjects were included in the study. After a median followup of 5.2 years, 1122 (64%) had died, including 247 (15%) deaths as a result of UBC. On multivariable analysis, cumulative duration of metformin use after NMIBC diagnosis did not appear to impact DSS (hazard ratio [HR] 1.1; 95% confidence interval [CI] 0.92-1.2), whereas glyburide use appeared to have a detrimental effect (HR 1.17; 95% CI 1.02-1.3). None of the other hypoglycemic agents had an impact on OS., Conclusions: In this large, population-based study, we have provided further evidence that metformin use does not significantly impact DSS among diabetic patients diagnosed with NMIBC. However, our findings demonstrate that glyburide use inversely affects DSS. The detrimental effect of glyburide on DSS will require further validation.

Testosterone suppression, achieved through orchiectomy or medically induced androgen-deprivation therapy (ADT), is a standard treatment for men with recurrent and metastatic prostate cancer. Current assay methods demonstrate the capacity for testosterone suppression to <0.7 nmol/l, and clinical data support improved outcomes from ADT when lower levels are achieved. Practical clinical guidelines are warranted to facilitate adoption of 0.7 nmol/l as the new standard castrate testosterone level.A pan-Canadian group of experts, representing diverse clinical specialties, identified key clinical issues, searched and reviewed relevant literature, and developed consensus statements on testosterone suppression for the treatment of prostate cancer. The expert panel found that current evidence supports the clinical benefit of achieving low testosterone levels during ADT, and encourage adoption of ≤0.7 nmol/l as a new castrate level threshold. The panel recommends regular monitoring of testosterone (e.g., every 3-6 months) and prostate-specific antigen (PSA) levels as clinically appropriate (e.g., every 3-6 months) during ADT, with reassessment of therapeutic strategy if testosterone is not suppressed or if PSA rises regardless of adequate testosterone suppression. The panel also emphasizes the need for greater awareness and education regarding testosterone assay specifications, and strongly promotes the use of mass spectrometry-based assays to ensure accurate measurement of testosterone at castrate levels.

Introduction: We aimed to compare the efficacy of two different sling tensioning approaches, and to report our experience, including safety and impact on quality of life (QoL) of the Virtue ® male sling for the treatment of postprostatectomy incontinence (PPI)., Methods: From our prospectively maintained database, we retrospectively identified all men treated with the Virtue male sling for PPI between March 2009 and February 2014 by two urologists in two institutions. Baseline demographic data and the sling tensioning method were abstracted from the database. Likewise, the Patient Global Impression of Improvement (PGI-I) scale, severity of incontinence, and clinical outcomes were also abstracted., Results: 48 patients were treated with the Virtue quadratic male sling. Sling tensioning was done using cystoscopy in the first 18 patients (Group 1), while per-operative retrograde leak point pressure (RLPP) measurement was done in the last 30 patients (Group 2). The median (interquartile range [IQR]) followup from the day of surgery was 22 (15-41) months. At the last followup visit, 7 (39%) patients in Group 1 were cured or improved of their PPI, compared to 21 (70%) patients in Group 2 (p=0.03). The final median (IQR) RLPP in these patients was 41 (37-48) cm H 2 O. Transient pain was the most common adverse event, occurring in 23 (48%) of patients. Twenty-one (70%) patients in Group 2 were "much better" or "very much better" with their device, compared to 7 (39%) in Group 1 (p=0.0008)., Conclusions: The Virtue male sling is a valuable treatment option for PPI. Per-operative RLPP measurement significantly improves cure and satisfaction rates., Competing Interests: Competing interests: The authors report no competing personal or financial interests.

Introduction: Active surveillance (AS) is a strategy for the management of low-risk prostate cancer (PCa). However, few studies have assessed the uptake of AS at a population level and none of these were based on a Canadian population. Therefore, our objectives were to estimate the proportion of men being managed by AS in Ontario and to assess the factors associated with its uptake., Methods: This was a retrospective, population-based study using administrative databases from the province of Ontario to identify men ≤75 years diagnosed with localized PCa between 2002 and 2010. Descriptive statistics were used to estimate the proportion of men managed by AS, whereas mixed models were used to assess the factors associated with the uptake of AS., Results: 45 691 men met our inclusion criteria. Of these, 18% were managed by AS. Over time, the rates of AS increased significantly from 11% to 21% (p<0.001). Older age, residing in an urban centre, being diagnosed in the later years of the study period, having a neighborhood income in the highest quintile, and being managed by urologists were all associated with greater odds of receiving AS., Conclusions: There has been a steady increase in the uptake of AS between 2002 and 2010. However, only 18% of men diagnosed with localized PCa were managed by AS during the study period. The decisions to adopt AS were influenced by several individual and physician characteristics. The data suggest that there is significant opportunity for more widespread adoption of AS.