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To determine the prevalence and natural history of nmCRPC prior to the adoption of novel androgen receptor axis-targeting therapies(ARAT).This was a retrospective population-based cohort study of men with nmCRPC in Ontario, Canada between January 2007-March 2018. Patients with prostate cancer, castrate level of testosterone(1.7nmol/L) and a PSA2.0ng/mL with a subsequent rise25% from the nadir, and without metastasis were included. Annual prevalence of nmCRPC was calculated. Crude time from nmCRPC to metastasis and all-cause death are presented as medians with interquartile range(IQR). Predictors of time from nmCRPC to death were compared using univariable and multivariable cox proportional hazard models.We identified 2045 patients with nmCRPC. Median age was 79(IQR:72-84). 984 patients(48.1%) received upfront hormonal therapy while 583(28.5%) received initial radiotherapy and 478(23.4%) underwent radical prostatectomy. Median time from primary treatment to nmCRPC was 6 years(IQR:3-10). The average annual prevalence of nmCRPC was 8% among men receiving ADT. Crude median time from nmCRPC to death was 37.6 months(IQR:22.1-55.4). Median time from nmCRPC to metastasis and metastasis to death was 20.0 and 8.3 months, respectively. Patients who had primary surgery experienced longer crude survival. Older patients, patients who had a higher PSA at nmCRPC, and patients with grade group 4 to 5 disease had a shorter time from nmCRPC to death.This is the largest population-level analysis of the prevalence and natural history of nmCRPC. The current study can be used as a historical cohort to compare how novel imaging modalities and ARAT impact prevalence and disease trajectory over time.

Background The differential risk of incident dementia associated with receiving various overactive bladder (OAB) drugs is unknown. Objective To estimate the association of antimuscarinic OAB drug (exposure), compared with a β-3 agonist (mirabegron), and incident dementia. Design, setting, and participants A population-based nested case-control study was conducted in patients treated with OAB medications in Ontario, Canada. A total of 11 392 patients aged ≥66 yr with a new diagnosis of dementia between 2010 and 2017, and 29 881 age- and sex-matched controls without dementia were included in the study. Intervention Receipt of an antimuscarinic OAB drug or receipt of mirabegron, within the previous 6–12 mo. Outcome measurements and statistical analysis Cases developed dementia and Alzheimer’s disease. Controls were derived from the general population and matched to cases based on important baseline characteristics. Odds ratios (ORs) for incident dementia, adjusted for demographic and health-related characteristics, were determined. Results and limitations Patients receiving solifenacin (OR 1.24; 95% confidence interval 1.08–1.43) and darifenacin (OR 1.30; 95% CI 1.08–1.56) in the prior 6 mo had increased odds of incident dementia compared with those receiving mirabegron. In the 6 mo to 1 yr prior to diagnosis, receipt of solifenacin (OR 1.34; 95% CI 1.11–1.60), darifenacin (OR 1.49; 95% CI 1.19–1.86), tolterodine (OR 1.21; 95% CI 1.02–1.45), and fesoterodine (OR 1.39; 95% CI 1.14–1.71) was associated with increased odds of incident dementia compared with receipt of mirabegron. No effect was seen with oxybutynin or trospium. Limitations included misclassification of the outcome and residual confounding associated with the use of health administrative databases. Conclusions Older adults receiving solifenacin and darifenacin in the 6 mo prior to diagnosis, and those receiving solifenacin, darifenacin, tolterodine, or fesoterodine in the year prior to diagnosis, have increased odds of incident dementia, compared with those receiving mirabegron. Oxybutynin and trospium were not associated with dementia, likely due to a protopathic bias. Careful drug selection is warranted when treating patients with OAB. Patient summary In a large Canadian cohort of patients who developed dementia after starting an overactive bladder (OAB) medication, those taking some anticholinergic medications for OAB have an increased risk of dementia compared with those taking mirabegron.

What is this summary about? This is a summary of a study originally published in Neurourology and Urodynamics . Overactive bladder is a medical condition that causes an urgent need to urinate, which can cause accidental urination. Fesoterodine is a medication used to treat overactive bladder. Because we don't know how likely it is that an individual patient will achieve a level of improvement in their overactive bladder symptoms, researchers analyzed results of 6 studies of patients with overactive bladder who were treated with fesoterodine. What were the results? Although complete resolution of all symptoms was rare with fesoterodine treatment, a resolution of accidental urination was more common, which is the most important treatment goal for many patients. After taking fesoterodine, episodes of accidental urination were more likely to be reduced or completely absent than episodes of an urgent need to urinate. What do the results of the study mean? These results can help patients with overactive bladder understand their own chances of treatment success with fesoterodine and can help doctors support their patients on what to expect regarding their specific symptoms and concerns. ▪ Toviaz (fesoterodine) is approved to treat the condition that is discussed in this summary. Approval varies from country to country; please check with your local health provider for more details. ▪ This summary reports the combined results of 6 studies. The results of individual studies may vary from the combined study results presented here. Individuals should make treatment decisions based on all available evidence. ClinicalTrials.gov NCT number: NCT01302054 , NCT01302067 , NCT00444925 , NCT00611026 , NCT00220363 , and NCT00138723

Near infrared spectroscopy (NIRS) is a non-invasive optical technique that uses near infrared light to detect the oxygenation status and hemodynamics of various organs. This article reviews the use of NIRS for the non-invasive assessment of lower urinary tract dysfunction (LUTD). Applications include assessment of bladder outlet obstruction, overactive and underactive bladder, neurogenic LUTD, pediatric LUTD, interstitial cystitis/bladder pain syndrome, and pelvic floor dysfunction. In addition, the article describes how NIRS is elucidating more about the brain-bladder connection. Technological advancements enabling these applications are also discussed.While evidence exists for the application of NIRS throughout a wide range of LUTD, most of these studies are limited by small sample sizes without matched controls. Investigators have experienced problems with reproducibility and motion artifacts contaminating the data. The literature is also becoming dated with use of older technology.NIRS holds potential for the non-invasive acquisition of urodynamic information over time scales and activities not previously accessible, but it is not yet ready for use in routine clinical practice. Advances in wearable technology will address some of the current limitations of NIRS, but to realize its full potential, larger scale validation studies will be required. Moreover, multidisciplinary collaboration between clinicians, scientists, engineers, and patient advocates will be critical to further optimize these systems.

To evaluate the long-term outcomes and impact of surgical modifications on the need for secondary surgery of the Hemi-Kock continent catheterizable stoma, comprising a detubularized ileal segment with an attached stapled ileoileal intussusception of the catheterizable channel, in patients with complex lower urinary tract disorders. The technique may be used for augmentation in patients with reduced bladder capacity who require a continent catheterizable channel. Compared to the flap and ileocecal valve procedures, the hemi-Kock technique has not been widely adopted.This is a retrospective case series including all patients who underwent a hemi-Kock catheterizable channel with cystoplasty from a single institution. Surgical technique and modifications in valve construction and tapering of the catheterizable limb are described.A total of 109 patients, with a median age of 38 years (range 18-72), underwent the procedure. At a mean of 10.4 years, 98 patients (90%) reported that they were managing with clean intermittent catheterization ± pads; 11 (10%) were failures. A total of 70 (64.2%) patients underwent secondary interventions with60% performed endoscopically or under local anesthesia, mainly for bladder stones. Fourteen patients (12.8%) required valve revisions. However, the rate decreased from 18.2% (8/44) to 9.3% (6/65) following incorporation of the surgical modifications.We present the largest cohort to date of patients managed with a Hemi-Kock catheterizable channel and cystoplasty. Valve revision rate improved with surgical modifications. We demonstrate long-term durability and maintenance of stomal catheterization in the vast majority of patients.

Introduction: Individuals with spina bifida (SB) may experience negative health outcomes because of an informal transition from pediatric to adult care that results in using the emergency room (ER) for non-acute health problems. Methods: We conducted a retrospective population-based cohort study of all people with SB in Ontario, Canada turning 18 years old between 2002 and 2011. These patients were followed for five years before and after age 18. Primary outcome was the annual rate of ER visits. Secondary outcomes included rates of hospitalization, surgery, primary care, and specialist outpatient care. We estimated the association between age with primary and secondary outcomes using negative binomial growth curve models, adjusting for patient-level baseline covariates. Results: Among the 1215 individuals with SB, there was no trend of ER visits seen with increasing age (relative risk [RR] 0.99, 95% confidence interval [CI] 0.98–1.02); however, there was a significant increase in the rate of ER visits associated with turning 18 years (RR 1.14, 95% CI 1.03–1.27). Turning 18 years old was also associated with a decreased rate of hospital admissions (RR 0.79, 95% CI 0.66–0.95) and no change in surgeries (RR 0.80, 95% CI 0.64–1.02). Visits to primary care physicians remained stable over the same period (RR 0.96, 95% CI 0.90–1.01), while visits to SB-focused specialists decreased after age 18 (RR 0.81, 95% CI 0.75–0.87). Conclusions: In patients with SB, the rate of ER visits increased significantly at 18 years old, while hospital admissions and specialist physician visits decreased at the same time. Models of transitional care can aim to reduce non-urgent ER visits and facilitate regular specialist care.

Introduction:Iatrogenic ureteral injuries (IUIs) are rare but can lead to significant consequences if unrecognized at the time of injury. We compare the impact of immediate vs delayed recog...

Objective To characterize afferent nipple valve obstruction in Kock diversions presenting with hydronephrosis and discuss appropriate work-up and management. Methods We retrospectively reviewed 7 cases of afferent nipple valve obstruction. Results The median time from diversion creation to afferent nipple valve intervention was 17-years. Presentations included febrile-UTIs, worsening renal function and hydronephrosis. All patients underwent upper tract imaging confirming bilateral hydronephrosis or hydronephrosis of a solitary kidney followed by nephrostomy tube insertion to drain the obstructed kidney(s). On nephrostogram assessment afferent nipple valve obstruction was confirmed by a lack of contrast passing through the valve. In 4 of these patients the afferent valve could not be cannulated while in one patient endoscopic retrograde balloon dilation was performed but failed after 12-months. One patient had successful antegrade balloon dilation (four-years follow-up). In five patients and the one patient who failed retrograde balloon dilation open surgical repair of the afferent nipple valve was successful (median follow-up time 5-years). Conclusion It is essential to consider afferent nipple valve obstruction in a patient with a Kock diversion presenting with bilateral hydronephrosis/hydronephrosis of a solitary kidney, even after many years following the original diversion. Appropriate work-up consists of upper tract imaging, endoscopy and retrograde studies or nephrostomy insertion with nephrostogram. Management options include endoscopic retrograde or antegrade balloon dilation or valve incision. Failing that, surgical repair may be successful with long-term upper tract preservation.

In this study we perform a review of the literature on systemic muscle weakness after administration of botulinum toxin A, to describe the factors that predispose patients to this adverse event and to suggest strategies for prevention. Our search criteria included the terms “Botulinum toxin, Abobotulinum toxin, Dysport®, Onabotulinum toxin, Botox®, Incobotulinum toxin and Xeomin®, muscle weakness, generalized muscle weakness and respiratory distress.” Statistical analysis was completed using IBM® SPSS software. We identified 2029 articles and narrowed this to 38 articles referencing 63 specific cases (including two studies form our institution) and 11 case series. Our analysis of 11 case series suggested that systemic muscle weakness is a rare event with botulinum toxin A. Of the 63 cases identified, the most common indications for use were spasticity (49.2%) and neurogenic detrusor overactivity (22.2%). The median age was low at 34 years, and the majority were female (76.2%). Furthermore, 47.6% of the cases were associated with the abobotulinum toxin A formulation. On average, the doses administered were 3.2 times the recommended dose (standard deviation 1.9) suggested for the particular botulinum toxin A formulation and indication. If systemic muscle weakness did occur, indication for botulinum toxin A being upper tract gastrointestinal disorder was associated with more severe impairment (W2 = 10.2, p = 0.001). Based on data from the identified cases of systemic muscle weakness with botulinum toxin A, this adverse event was more common in female, younger, patients with spasticity or neurogenic detrusor overactivity indication or those receiving abobotulinum toxin A formulation and/or higher botulinum toxin A doses. A prevention strategy may include reducing the dose of botulinum toxin A to those recommended by the US FDA.

Aim This study describes patients with different degrees and combinations of symptom resolution in response to fesoterodine exposure to aid physicians in counselling patients with overactive bladder (OAB) on the likelihood of treatment success. Methods Data came from 12‐week fixed‐dose studies of fesoterodine. The proportions of patients experiencing symptom resolution and change in patient‐reported outcome measures (PROM) at 4, 8, and 12 weeks were calculated. Treatment‐emergent adverse events (TEAE) were reported according to response in urinary urgency episodes (UUE). The relationship between PROM and response was examined. Results Out of 6689 patients, 81.6% female, urgency urinary incontinence (UUI) episodes/24 h were more responsive to fesoterodine than UUE; with roughly 50% of patients reporting a 50% reduction and fewer than 10% reporting absence of UUE at 12 weeks compared to approximately 40%–50% reporting absence of UUI. TEAE was numerically lower in patients with greater response. There was a statistically significant relationship between improvement in urinary urgency and associated change in OAB‐q symptom bother scores, r = 0.54, p

Objective To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence. Patients and Methods A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications. Results Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P Conclusion ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

OBJECTIVE To analyze the safety of mirabegron add-on therapy in men with overactive bladder symptoms concurrently receiving tamsulosin for lower urinary tract symptoms associated with benign prostatic hyperplasia. METHODS The Phase 4 PLUS study comprised a 4-week run-in period (tamsulosin [0.4 mg]) and a 12-week randomized treatment period (add-on treatment: mirabegron [25 mg] or placebo). Doses were increased to mirabegron 50 mg or matched placebo after 4 weeks. Safety assessments: treatment-emergent adverse events (TEAEs), vital signs, 12-lead electrocardiograms, and changes in postvoid residual volume and maximum urinary flow (Qmax). RESULTS The safety analysis set included 352 tamsulosin plus mirabegron (TAM + MIRA) and 354 tamsulosin plus placebo (TAM + PL) patients. The frequency of overall TEAEs was higher with TAM + PL, although a higher incidence of drug-related TEAEs was observed with TAM + MIRA. Most TEAEs were mild or moderate in severity. Drug-related serious TEAEs were reported for 3 patients (2 TAM + MIRA patients: acute myocardial infarction with cerebral infarction and angina pectoris, 1 TAM + PL patient: lacunar stroke). Hypertension, headache, and nasopharyngitis were the most common TEAEs. Special interest TEAEs were infrequently reported. The most common was urinary retention and 2 TAM + MIRA patients required catheterization (neither led to discontinuation). No major changes in blood pressure or pulse rate were noted and similar electrocardiogram parameters were observed for both groups. Changes in mean postvoid residual volume and Qmax were not clinically meaningful. CONCLUSION No unexpected safety concerns were noted in men receiving tamsulosin for lower urinary tract symptoms associated with benign prostatic hyperplasia who subsequently received mirabegron add-on therapy.

Background The rate of primary and secondary treatment while on active surveillance (AS) for localized prostate cancer at the general population level is unknown. Our objective was to determine the patterns of secondary treatments after primary surgery or radiation for patients who undergo AS. Methods This was a population‐based retrospective cohort study of men aged 50‐80 years old in Ontario, Canada, between 2008 and 2016. We identified 26 742 patients with prostate cancer, a Gleason grade score ≤7, and an index prostate‐specific antigen ≤10 ng/mL. Patients were categorized as undergoing AS with or without delayed primary treatment (DT; treatment >6 months after diagnosis) versus immediate treatment (IT; treatment ≤6 months). Patients receiving DT and IT were propensity score matched and the rate of secondary treatment (surgery or radiation ± androgen deprivation treatment) was compared using Cox proportional hazards models. Results We identified 10 214 patients who underwent AS and 11 884 patients who underwent IT. Among patients undergoing AS, 3724 (36.5%) eventually underwent DT and among them, 406 (10.9%) underwent secondary treatment. The median time to DT was 1.2 years (IQR 0.5‐8.1 years). The relative rate of undergoing secondary treatment was similar in the DT vs IT group (HR 0.92; 95% CI: 0.79‐1.08). The risk of death in the DT group was higher compared to patients who did not undergo treatment (HR 1.23, 95% CI: 1.01‐1.49). Conclusions Among patients with localized prostate cancer on AS, one third undergo DT. The rate of secondary treatment was similar between the DT and IT groups. Patients in the DT group may experience a higher risk of mortality compared to those who remained on AS., For men with localized prostate cancer who are candidates for active surveillance, one third receive delayed primary treatment. Active surveillance is a safe approach, as there appears to be no adverse risk of progression with similar rates of secondary treatment compared to patients who underwent immediate treatment.

Background In older patients with overactive bladder (OAB), mirabegron, a β3-adrenoreceptor agonist, represents an alternative treatment that may have a favorable risk–benefit profile. Objectives Our objective was to further examine the safety and tolerability of mirabegron versus placebo treatment in patients aged ≥ 65 years with OAB-wet. Methods We conducted a 12-week, double-blind, randomized, placebo-controlled phase IV study to compare mirabegron with placebo. Community-dwelling patients aged ≥ 65 years with OAB-wet (one or more incontinence episode and three or more urgency episodes, and an average of eight or more micturitions/24 h over a 3-day diary) were randomized to receive placebo or mirabegron 25 mg/day (optional dose escalation to 50 mg/day at week 4 or 8). Safety analyses were performed for adverse events (AEs) and vital signs on all randomized patients who received one or more dose of study drug. Results Treatment-emergent AEs (TEAEs), the majority mild or moderate in severity, were reported in 39.4% of placebo patients and 44.2 and 49.8% of those who received mirabegron 25 mg or 50 mg, respectively. The most common TEAEs in mirabegron-treated patients were urinary tract infection, headache, and diarrhea. The incidence of TEAEs was slightly higher in mirabegron patients aged ≥ 75 years than in those aged

Purpose:Previous studies have shown an association between urinary incontinence and increased mortality independently of demographics and health status. However, they do not account for the effect ...

Mirabegron, a β3-adrenoreceptor agonist, is an alternative drug to antimuscarinics for overactive bladder (OAB) symptoms.To summarise safety and efficacy reporting of mirabegron treatment for OAB symptoms.Pooled data analysed from 10 phase 2-4, double-blind, 12-wk mirabegron monotherapy studies in adults with OAB who had received one or more doses of study drug.Mirabegron: 25 and 50mg; antimuscarinics: solifenacin (2.5, 5, and 10mg) and tolterodine extended release (4mg).Baseline OAB-related characteristics, intrinsic and extrinsic factors, and analyses by age (65 vs ≥65yr and75 vs ≥75yr) and sex were assessed. Solifenacin 2.5 and 10mg groups were not included in the efficacy analyses (small patient numbers). Safety was evaluated using the proportion of treatment-emergent adverse events. Efficacy variables were derived from bladder diaries (baseline and week 12).Baseline hypertension and diabetes were more frequent across treatment groups in the older versus younger age groups and in men versus women. Within sexes, frequencies were similar between treatment groups. Some differences were observed in baseline characteristics, including type of incontinence and medical history between sexes. No previously unreported safety concerns were identified. Improvements in efficacy (mean number of incontinence episodes/24h, micturitions/24h, urgency episodes/24h, volume voided/micturition, and nocturia episodes) versus placebo were observed in all treatment groups. Significant treatment-by-subgroup interactions included change from baseline in the mean number of incontinence episodes/24h by age (65 vs ≥65yr), nocturia by age (65 vs ≥65yr and75 vs ≥75yr), and urgency episodes by previous OAB medication.Data from this integrated database of 10 mirabegron studies reaffirm the safety and efficacy profiles of mirabegron, solifenacin, and tolterodine in adults of different age groups and sexes.Overactive bladder is a complex of symptoms including a compelling desire to pass urine that leads to increased frequency, which may lead to a degree of incontinence if you do not reach the toilet in time and may wake you from sleep. We pooled data from 10 different studies of mirabegron in patients with overactive bladder symptoms, and looked at the effect in the total number of patients who received the treatment, as well as in different age groups and between men and women. No new safety concerns were identified, and mirabegron improved the symptoms of overactive bladder.

Appendico-vesical fistula (AVF) is an uncommon type of enterovesical fistula that can present with symptoms of recurrent or persistent urinary tract infection (UTI) and, in some instances, with gastrointestinal symptoms. AVFs occur more commonly in males and are mainly attributed to unrecognized or conservatively managed appendicitis.1 Herein, we describe a case of a 21-year-old male who presented with fevers, urgency, and hematuria and on extensive workup was found to have an AVF requiring surgical repair. Drawing from our case and the literature, we conclude that AVF occurs rarely and requires a high index of suspicion among physicians. Past medical history of previous acute appendicitis and UTIs with or without gastrointestinal symptoms should raise suspicion for AVF.

Objective To compare the long-term outcomes of initial management of pelvic fracture urethral injury (PFUI) in a large cohort of trauma patients undergoing urethral reconstruction. Materials and Methods 119 patients underwent urethral reconstruction by a single surgeon for PFUI at our centre between 1998-2018. We compared initial PFUI management - primary re-alignment versus suprapubic tube (SPT) insertion alone. Multivariable Cox proportional hazard analysis was used to assess the association between primary intervention and the risk of having a complication. Results PFUI was initially managed with primary realignment (57%) or SPT alone (43%). Ultimately, all patients underwent a primary perineal urethral anastomosis after a median of 7 months (IQR: 5-14). Overall, 27 patients (23%) had one or more long-term complications after a median 25 months (IQR:7-66), including urethral stricture, de novo erectile dysfunction, and urinary incontinence. On multivariable analysis, initial PFUI management did not predict for complications. Conclusions No difference was found in long-term outcomes after urethral reconstruction when comparing initial PFUI management of primary re-alignment versus SPT insertion.

ObjectivesTo compare the risk of bladder cancer and bladder cancer mortality among patients with chronic bladder catheterisation (indwelling or intermittent) to patients from the general population.DesignRetrospective cohort study.SettingPopulation-based study in Ontario, Canada between 2003 and 2018.ParticipantsAdult patients 18–90 years of age with chronic bladder catheterisation were hard matched to patients from the general population without a history of bladder catheterisation.InterventionsThe presence of a chronic catheter was defined as a minimum of two physician encounters for bladder catheterisation, suprapubic tube insertion or home care for catheter care separated by at least 28 days. Urinary tract infection (UTI) rates were collected.Main outcome measuresBladder cancer and bladder cancer-specific mortality after a 1-year lag period were compared between groups.ResultsWe identified 36 903 patients with chronic catheterisation matched to 110 709 patients without a history of catheterisation. Patients were followed for a median of 8.8 years (IQR: 5.2–11.9 years). The median age was 62 years (IQR: 50–71) and 52% were female. More patients in the catheter group developed bladder cancer (393 (1.1%) vs 304 (0.3%),pConclusionsThis is the first study to quantify the increase in bladder cancer incidence and mortality in a large, diverse cohort of patients with chronic indwelling or intermittent bladder catheterisation. The risk was highest among patients with a chronic catheter beyond 2.9 years.

Introduction: Although intraoperative iatrogenic ureteric injuries (IUI) are rare, significant consequences can occur if they are unrecognized at the time. The focus of our study is to characterize the associated morbidity and identify predictors of delayed recognition of IUI. Methods: Sunnybrook Health Sciences Centre Research Ethics Board approved the study. Patients with a diagnosis of IUI between 2002 and 2020 were identified through an institutional electronic medical record system. Data pertaining to the demographic characteristics, diagnosis, and management of IUI and overall outcomes were collected retrospectively. Results: Of the 103 patients identified, 83% were female, 52% had previous abdominal surgery, and 18% had previous radiation. The median age was 67 (21–88) years. Twenty percent were not recognized at the time of surgery. Although delayed recognition was not a significant predictor for poor outcome after subsequent repair (i.e., hydronephrosis, ureteric stricture/obstruction), it was associated with substantial morbidity to the patient (i.e., additional procedures) and increased cost to the healthcare system (i.e., longer hospital stay, readmission to hospital). Patients who underwent laparoscopic surgery had an 11 times more likely chance of having an unrecognized IUI as compared to those who underwent open surgery (odds ratio 11.515, p=0.0001). Conclusions: Delayed recognition of IUI may be associated with considerable adverse effects. In this retrospective case series, we identified laparoscopic surgery as a significant predictor for delayed recognition of IUI. This information underscores the need for future studies to facilitate intraoperative identification of ureteric injuries, particularly during laparoscopic procedures.

Context Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. Objective To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. Evidence acquisition A collaborative narrative review of the literature from 2010 to present was conducted. Evidence synthesis Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3–9% and 0–4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4–14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. Conclusions There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. Patient summary In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.

Introduction In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report. Methods This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Results A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text. Conclusions A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Aims SYNERGY II was a 12‐month phase III trial in patients with overactive bladder (OAB) symptoms that investigated the safety and efficacy of the combination of mirabegron and solifenacin in comparison with each monotherapy. This analysis evaluated the trial findings using four age subgroups (1 bpm were noted in the combination and mirabegron younger age groups only. No clinically significant findings were observed in the other safety parameters. The efficacy variables improved with all treatments and the greatest improvements were typically observed with combination therapy. Conclusions Mirabegron and solifenacin combination therapy was a well‐tolerated and effective treatment for patients with OAB symptoms irrespective of their age.

Psychological distress is prevalent among men with prostate cancer (PCa). However, the variation in antidepressant use among individuals throughout the survivorship period is unknown. We sought to examine the variation and trends in receipt of antidepressants after PCa treatment, among patients with nonmetastatic PCa. Using population-based linked administrative data, we identified men ≥66 yr old who underwent surgery (n=4952), radiotherapy (n=4994), or surveillance (n=2136), and these men were matched to general population controls (n=57127). One year prior to PCa treatment, 7.7% of men received an antidepressant prescription, which increased to 10.5% in the year after treatment. In difference-in-differences analysis, adjusted for demographic and health characteristics, men had increased odds of antidepressant receipt up to 5 yr after surgery (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.35–1.64; p≤0.0001) or radiotherapy (OR 1.33; 95% CI 1.21–1.47; p≤0.0001). Men did not have an increased risk of antidepressant receipt up to 5 yr after surveillance (OR 1.15; 95% CI 0.94–1.41; p=0.16). Limitations include the potential for selection bias and misclassification due to the retrospective design of the study and the use of administrative databases. Thus, men with nonmetastatic PCa who initially receive surgery or radiotherapy, but not those who initially undergo surveillance, have an increased risk of antidepressant receipt after treatment. Patient summary In this report, we examined antidepressant prescription for men after treatment of nonmetastatic prostate cancer across the entire population of men ≥66 yr in Ontario, Canada, from 2002 to 2009. For men diagnosed with nonmetastatic prostate cancer, the risk of antidepressant receipt at 5 yr after treatment was significantly increased after surgery or radiotherapy, but not after surveillance. Providers and patients should consider the psychological effects of prostate cancer treatment during the survivorship period.

Introduction: Approximately 50% of all high-grade renal traumas (HGRT, American Association for the Surgery of Trauma [AAST] grade 4/5) have associated collecting system injuries. Although most of these collecting system injuries will heal spontaneously, approximately 20–30% of these injuries are managed with ureteric stents. The objective of the study was to review the management of HGRT with collecting system injuries in a level 1 trauma center. Methods: This was a single-center, retrospective cohort study of trauma patients with HGRT and collecting system injuries from 1998–2019. Results: We identified 147 patients with HGRT. Of the 105 patients who had trauma computed tomography (CT) imaging within 24 hours, 46 were found to have collecting system injuries. Seven of these patients underwent intervention based on initial CT findings; the remaining 39 patients with urinary extravasation were conservatively managed. Of the 37 patients who underwent reimaging, 22 (59%) demonstrated a stable or resolving collection and 15 (41%) demonstrated continued urinary extravasation. Resolution of extravasation on subsequent imaging was observed in 10 of those patients, while five patients (14%) required intervention (four stents, one percutaneous drain) for symptoms/signs of urinary extravasation. Conclusions: In this study, most patients with HGRT and collecting system injuries did not require intervention unless the patient became symptomatic. The majority of collecting system injuries resolved with no intervention. This study underscores the need for future prospective trials to investigate the necessity of intervening in HGRT collecting system injuries and, secondarily, the need for routine reimaging in these asymptomatic patients.

For patients with neurogenic detrusor overactivity incontinence (NDOI), treatment with oral medications is often unsatisfactory.To assess the efficacy and safety of abobotulinumtoxinA (aboBoNT-A) for NDOI.Two randomized, double-blind phase 3 studies (CONTENT1, NCT02660138; CONTENT2, NCT02660359) enrolled patients with NDOI who were regularly performing clean intermittent catheterization (CIC) and were inadequately managed with oral therapy. Pooled results from the first placebo-controlled treatment cycle are reported.Patients received injections of aboBoNT-A 600 U (n = 162) or 800 U (n = 161) or placebo (n = 162) into the detrusor muscle.The primary endpoint was the mean change from baseline in NDOI episodes per week at week 6. Secondary endpoints reported are the proportion of patients with no NDOI episodes, the volume per void, urodynamic parameters, and quality of life (QoL). Safety was also assessed. Statistical analyses were conducted for the pooled study populations (each aboBoNT-A dose vs placebo).At week 6, NDOI episodes per week were significantly reduced in each aboBoNT-A group versus placebo (both p0.001) and the volume per void had significantly increased. Approximately one-third of patients in each aboBoNT-A dose group reported no NDOI episodes versus 3% of patients in the placebo group. Reductions in urinary incontinence (UI) were reflected in significantly greater improvements in UI-related QoL in the aboBoNT-A groups versus placebo. Urodynamic parameters (bladder capacity and detrusor pressure) were significantly improved with each aboBoNT-A dose versus placebo. Each aboBoNT-A dose was well tolerated. Symptomatic urinary tract infection was the most frequent treatment-emergent adverse event, with incidence comparable across the aboBoNT-A and placebo groups. The studies were terminated prematurely owing to slow recruitment and were not designed for statistical comparison between the two aboBoNT-A doses.Intradetrusor aboBoNT-A is an effective treatment and alternative option for patients with NDOI who have an inadequate response to oral anticholinergics and are already performing CIC.In patients with bladder muscle overactivity caused by neurological conditions (multiple sclerosis or spinal cord injury) and resulting in urinary incontinence, abobotulinumtoxinA injections improved their symptoms and bladder function, with no unexpected effects.

Introduction: We sought to review outcomes of urethrovaginal fistula (UVF) repair, with or without concurrent fascial sling placement. Methods: All patients diagnosed with UVF at our center from 1988–2017 were included in this study. Patient charts were reviewed from a prospectively kept fistula database, and patient characteristics and surgical outcomes were described. Descriptive statistics were applied to compare complication rates between patients with or without fascial sling placement at the time of UVF repair. Results: A total of 41 cases of UVF were identified, all of which underwent surgical repair. Median age at diagnosis was 49 years (interquartile range [IQR] 35–62). All patients had undergone pelvic surgery. UVF etiology was secondary to stress urinary incontinence (SUI) surgery in 17 patients (41%) and urethral diverticulum repair in seven patients (17%). The most common presenting symptom was continuous incontinence in 19 patients (46%). Nineteen patients had a fascial sling placed at the time of surgery (46%), with no significant difference in complication rates (26% vs. 23%, p=0.79). Two patients had Clavien-Dindo grade I complications (5%) and one had a grade III complication (2%). Four patients had long-term complications (10%), including urinary retention, chronic pain, and urethral stricture. Two patients had UVF recurrence (5%). Median followup after surgery was 21 months (IQR 4–72). Conclusions: UVF should be suspected in patients with continuous incontinence following a surgical procedure. Most UVF surgical repairs are successful and can be done with concurrent placement of a fascial sling.

Key Points Question What is the rate of secondary sarcoma among patients with nonmetastatic cancer of the prostate, bladder, colon, rectum or anus, cervix, uterus, or testis who were treated with combinations of surgery, radiation, or chemotherapy compared with patients treated with surgery alone and with the general population? Findings In this cohort study of 173 580 patients, the rate of secondary sarcoma among patients treated with radiotherapy was increased compared with patients who had surgery alone and with the general population. The risk was highest among those who received both chemotherapy and radiotherapy. Meaning This study provides further evidence to support the association of radiotherapy with secondary sarcoma; the finding of an increase in risk with combination radiotherapy and chemotherapy, in particular, merits further study., This cohort study compares the risk of secondary sarcoma among patients treated with combinations of surgery, radiation, and chemotherapy with patients treated with surgery alone and with the general population., Importance The association of radiation and chemotherapy with the development of secondary sarcoma is known, but the contemporary risk has not been well characterized for patients with cancers of the abdomen and pelvis. Objective To compare the risk of secondary sarcoma among patients treated with combinations of surgery, radiation, or chemotherapy with patients treated with surgery alone and the general population. Design, Setting, and Participants This population-based cohort study included 173 580 patients in Ontario, Canada, with nonmetastatic cancer of the prostate, bladder, colon, rectum or anus, cervix, uterus, or testis. Patients were enrolled from January 1, 2002, to January 31, 2017. Data analysis was conducted from March 1, 2019, to January 31, 2020. Exposures Treatment combinations of radiation, chemotherapy, and surgery. Main Outcome and Measures Diagnosis of sarcoma based on histologic codes from the Ontario Cancer Registry. Time to sarcoma was compared using a cause-specific proportional hazard model. Results Of 173 580 patients, most were men (125 080 [72.1%]), and the largest group was aged between 60 and 69 years (58 346 [33.6%]). Most patients had genitourinary cancer (86 235 [51.4%]) or colorectal cancer (69 241 [39.9%]). Overall, 64 301 (37.1%) received surgery alone, 51 220 (29.5%) received radiation alone, 15 624 (9.0%) were treated with radiation and chemotherapy, 15 252 (8.8%) received radiation with surgery, and 11 822 (6.8%) received all 3 treatments. A total of 332 patients (0.2%) had sarcomas develop during a median (interquartile range) follow-up of 5.7 (2.2-8.9) years. The incidence of sarcoma was 0.3% among those who underwent radiation alone (138 of 51 220) and radiation with chemotherapy (40 of 15 624), 0.2% among those who received radiation and surgery (36 of 15 252) and all 3 modalities (25 of 11 822), and 0.1% among those who received surgery with chemotherapy (13 of 14 861) and surgery alone (80 of 64 801). Compared with a reference group of patients who had surgery alone, the greatest risk of sarcoma was found among patients who underwent a combination of radiation and chemotherapy (cause-specific relative hazard [csRH], 4.07; 95% CI, 2.75-6.01; P

Aims To identify risk factors for urinary retention following AdVance™ Sling placement using preoperative urodynamic studies to evaluate bladder contractility. Methods A multi-institutional retrospective review of patients who underwent an AdVance Sling for post-prostatectomy stress urinary incontinence from 2007 to 2019 was performed. Acute urinary retention (AUR) was defined as the complete inability to void or elevated post-void residual (PVR) leading to catheter placement or the initiation of intermittent catheterization at the first void trial postoperatively. Bladder contractility was evaluated based on preoperative urodynamics. Results Of the 391 patients in this study, 55 (14.1%) experienced AUR, and 6 patients (1.5%) had chronic urinary retention with a median follow-up of 18.1 months. In total, 303 patients (77.5%) underwent preoperative urodynamics, and there was no significant difference between average PdetQmax (26.4 vs. 27.4 cmH2 O), Qmax (16.6 vs. 16.2 ml/s), PVR (19.9 vs. 28.1 ml), bladder contractility index (108 vs. 103) for patients with or without AUR following AdVance Sling. Impaired bladder contractility preoperatively was not predictive of AUR. Time to postoperative urethral catheter removal was predictive of AUR (odds ratio, 0.83; 95% confidence interval, 0.73-0.94; p = .003). Conclusions Chronic urinary retention after AdVance Sling placement is uncommon and acute retention is generally self-limiting. No demographic or urodynamic factors were predictive of AUR. Patients who developed AUR were more likely to have their void trials within 2 days following AdVance Sling placement versus longer initial catheterization periods, suggesting that a longer duration of postoperative catheterization may reduce the occurrence of AUR.

Introduction: We aimed to evaluate the success of bladder neck injections of triamcinolone at the time of transurethral bladder neck incision (BNI) for prevention of recurrent vesicourethral anastomotic stenosis (VUAS) following prostate cancer treatment. Methods: This is a retrospective cohort study examining patients with recurrent VUAS post-RP ± radiation treated with triamcinolone injections at the time of BNI. VUAS was diagnosed by symptoms followed by cystoscopy or urethrography. The outpatient procedures were done under general anesthesia. Cold knife incisions were made at the three, nine, and 12 o’clock BN positions, followed by triamcinolone injections (4 mg/mL) into the three and nine o’clock incision sites. Treatment outcomes were determined with cystoscopy. Results: Eighteen men underwent 25 procedures over a four-year period. Median age at diagnosis of VUAS was 65 (interquartile range [IQR] 61–68); median time to VUAS from RP was eight months (IQR 5–12). Fourteen patients (78%) had radiation treatment. The cohort had 128 unsuccessful VUAS treatments, with a median of five failed treatments per patient (IQR 3–10). Failed treatments included BN dilation, BNI, BN injection of mitomycin C, and urethral stent placement. Success rate after a mean of 16.3 months (standard deviation [SD] 8.1) from the time of triamcinolone injection was 83% (15/18). Six patients went on to have successful incontinence surgery. Five patients (28%) had treatment complications (bleeding, urinary tract infection, pain, and urinary extravasation). The three non-responders are stable and awaiting re-treatment with triamcinolone injection. Conclusions: Triamcinolone bladder neck injections for post-RP VUAS are a useful and safe treatment for recurrent stenosis.

Introduction: We sought to assess seven-day and 30-day complications following renal mass biopsy (RMB), including mortality, hospitalizations, emergency department (ED) visits, and operative and non-operative complications and compare these to rates in population matched controls. Methods: We performed a population-based, matched, retrospective cohort study of patients undergoing RMB following consultation with a urologist and axial imaging from 2003–2015 in Ontario, Canada. Data on seven-day and 30-day rates of mortality, operative and non operative complications after RMB were reported. The seven-day and 30-day rates of mortality, operative and non-operative interventions, hospitalizations, and ED visits were compared to matched controls using multivariable logistic regression. Results: Among 6840 patients who underwent RMB in the study period, 24 (0.4%) and 159 (2.3%) died within seven and 30 days, respectively, of their biopsy. Seven- and 30-day operative intervention rates were 79 (1.2%) and 236 (3.4%), respectively. Seven- and 30-day non-operative intervention rates were 227 (3.3%) and 529 (7.7%) respectively. Thirty-day mortality (odds ratio [OR] 8.1; 95% confidence interval [CI] 5.1–13.0), hospitalizations (OR 12.6; 95% CI 10.6–15.2), and ED visits (OR 3.8; 95% CI 3.4–4.3) were more common among patients who underwent RMB than the matched controls (p

Introduction: With the cessation of non-urgent clinical office visits due to the coronavirus, there has been a rapid shift to telephone and other virtual visits in outpatient practice. We conducted a survey to evaluate patients’ perspective of telephone visits during the COVID-19 pandemic. Methods: Patients receiving a scheduled telephone call, as a virtual visit, from urologists at our clinic were asked to participate in a three-minute, self-administered, online questionnaire. After verbal permission was obtained, the survey was emailed to each participant. The outcomes evaluated were telephone visit satisfaction and preference for type of appointment. Non-parametric tests were used to analyze the results. The study was approved by the Sunnybrook Research Ethics Board. Results: A total of 102 participants were included; 96% of participants assessed the telephone visit as a positive experience in every survey question, while 45% expressed no preference. In those who expressed a preference, this was evenly divided between in-office visits and phone visits (p=0.0614). Participants who lived more than 75 km from the hospital were less likely to prefer an in-office visit compared to those residing locally (U=433; p=0.006; odds ratio 0.29; 95% confidence interval 0.106–0.779; p=0.0142). Conclusions: In this survey, most participants assessed the telephone visit positively. Almost half had no preference and a similar proportion expressed a preference for in-office and telephone visits. Patients who resided farther from the hospital were more likely to prefer the telephone visit. This is the first study that we know of to assess patients’ preferences regarding remote encounters in urology.

INTRODUCTION AND OBJECTIVE:Regulatory warnings for mesh-based stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures have led to an unsupported claim that mesh directly stimul...