Characterization and Outcomes of Iatrogenic Urethral Catheterization Injuries

INTRODUCTION

Iatrogenic injury during urethral catheterization is a common reason for inpatient urologic consultation and is associated with increased morbidity and resource utilization. Literature defining the patient population, interventions, or outcomes associated with traumatic catheterization is scarce.

METHODS

We performed a retrospective review of consults for adult urethral catheterization at a single tertiary care center (July 2017-December 2019), with focus on patient characteristics and complications. Traumatic urethral catheterization was defined as catheterization by the primary team with at least 1 of these conditions: gross hematuria, meatal blood, or cystoscopic evidence of urethral trauma. Characteristics collected included urologic history, catheterization circumstances, procedural intervention, and subsequent visits.

RESULTS

Three hundred urology consults for urethral catheterization were identified, including 98 (33%) traumatic events (5.3 incidents/1000 catheters placed). All traumatic catheterization consults were in men (median age 69 years). Most (71%) patients sustaining injury had significant urologic history (eg, benign prostatic hyperplasia, urethral stricture). Sixty-three (64%) consults were determined to be uncomplicated (not requiring any procedural intervention for catheter placement). Gross hematuria was the most common sequela (50% of patients). The 30-day catheter-associated urinary tract infection rate was 13%, and 2 patients developed sepsis. Complications required a total of 52 additional hospital admission days, 19 of which were intensive-care level, as well 113 outpatient urology visits.

CONCLUSIONS

Traumatic urethral catheterization is associated with increased need for procedural intervention, risk of catheter-associated urinary tract infection, and additional resource utilization. Further studies on traumatic catheterization are needed to guide systemic efforts for minimizing injury and cost.

Pelvic floor therapy program for the treatment of female urinary incontinence in Belize: a pilot study

Introduction

Urinary incontinence (UI) is highly prevalent in low- and middle-income countries (LMIC). Concurrently, the availability of surgical or conservative UI treatments in LMIC is limited.

Methods

We conducted a prospective feasibility study of Belize women with UI treated with pelvic floor physical therapy (PFPT) and education (PFE). Patients received individual PFPT/PFE over 2 days, consisting of biofeedback-enhanced PFMT in addition to behavioral, dietary, and general pelvic education. Patient completed a daily 6-month home regimen including 7 PFMT exercises (total 70 repetitions) comprising both endurance and quick flick exercises. Patients also performed comprehensive dietary and behavioral modification activities. Outcomes were assessed at baseline and 6-months, including validated symptom (ICIQ-FLUTS) and QOL (IIQ-7) questionnaires, and strength testing (PERFECT score, perineometry).

Results

Twenty-eight patients underwent baseline assessment. Four patients were lost to in-person 6-month follow-up, with two of these patients completing subjective assessment only by telephone. The mean (±SD) patient age, BMI, and parity were 50.0 (±10.0) years, 33.2 (±5.8), and 2.8 (±1.5). Provider assessment demonstrated patient comprehension of basic, endurance, and quick flick pelvic floor contractions in 28 (100%), 24 (86%), and 24 (86%) patients, respectively. At 6-month follow-up, significant improvements were seen across multiple validated questionnaire and strength measurement assessments. Median patient-reported improvement level was 7.0 on a 10-point Likert scale.

Discussion

Study patients demonstrated good understanding of PFMT/PFE and program completion was associated with significant improvements across a variety of subjective incontinence and quality of life outcomes, as well as objective strength testing.

Pilot Study of a Novel Online Comprehensive Pelvic Floor Program for Urinary Incontinence in Women

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is common in women and has a vast impact on quality of life (QOL), financial health, and work disability. Robust evidence demonstrates the efficacy of comprehensive conservative therapy (pelvic floor muscle training [PFMT], and behavioral and dietary modification) in the treatment of UI. However, numerous barriers impede access to this care, including limited specialized therapists, financial barriers, and scheduling obstacles. To address these barriers, we developed a novel comprehensive online pelvic floor program (oPFP).

METHODS

We performed a prospective study assessing continence and QOL outcomes in women with stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) treated with oPFP between May 2019 and November 2022. Outcomes were assessed at baseline and following completion of the 2-month program using the validated International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, Urgency Perception Scale (UPS), Incontinence Impact Questionnaire (IIQ-7) questionnaires, and 24-h bladder diary. Data were analyzed using linear, Poisson mixed models, or generalized estimating equations.

RESULTS

Twenty-eight women (2 SUI, 3 UUI, 23 MUI) were enrolled and 19 (2 SUI, 2 UUI, 15 MUI) completed the study. Following oPFP, participants showed significantly improved SUI domain scores (3.04 ± 0.19 vs 1.81 ± 0.23, p < 0.001), UPS reason score (2.52 ± 0.18 vs 2.05 ± 0.14, p = 0.003), IIQ-7 sum scores (5.16 ± 0.88 vs 3.07 ± 0.70, p = 0.038), and daily incontinence episodes (2.96 ± 0.60 vs 1.06 ± 0.29, p < 0.001). Mean patient-reported improvement was 5.4 ± 2.5 (ten-point Likert scale). Of respondents, 89% reported program satisfaction, ease of use, and would recommend the program to others.

CONCLUSION

The oPFP results in significant improvements to a variety of UI and QOL measures. This program provides an important UI treatment option and gives women greater access to effective conservative therapy.

Urologic Consultations for Urethral Catheter Placement: A Cost Analysis

OBJECTIVE

To comprehensively analyze the cumulative costs associated with Foley consultations throughout their event lifespan. Urologic consultation for Foley catheter (Foley) management is common. Such consultations are heterogeneous, with some requiring only simple catheter placement. Others (eg, traumatic Foley) necessitate more complex procedural intervention and may also result in downstream care and/or intervention needs.

METHODS

This study analyzed a retrospective database of consecutive urologic Foley consultations at a single academic institution (2017-2019), collecting comprehensive data on patient characteristics, related procedures/materials, and downstream care (eg, hospitalization, laboratory/radiology testing, evaluation and management services). A process map and related modeling were used to assess categorical and cumulative event costs. Allocated costs and charges were utilized for materials/institutional resources and for services rendered, respectively. Statistical analysis performed using SAS and statistical inferences were based on significance level of 10%.

RESULTS

A total of 244 patient encounters were included in the analysis. The mean overall cost of all care related to Foley consultation was $2389.23 (±$4045.89). A total of 62 (25.4%) patients required only consultation/Foley without additional intervention, with a total cost of $738.90 (±$94.10). The remaining 182 (75.6%) patients required additional intervention and related cost (total cost $3413.27 (±$4850.41)). Traumatic catheterization was associated with higher cost compared with atraumatic cases ($3201.50 (±$6158.4) vs $1926.40 (±$1776.20), respectively, P = .05). Downstream care comprised a significant portion of overall cost. In 61 (25%) cases no nurse attempt was performed prior to consultation.

CONCLUSION

Urologic Foley consultation is associated with significant health system cost. Quality initiatives to optimizing Foley placement and management are critical to improving quality of care and associated downstream costs.

Novel online comprehensive pelvic floor therapy program following prostatectomy

Background

Although pelvic floor muscle training (PFMT) is widely shown to improve post-prostatectomy incontinence (PPI), numerous barriers impede access to formal PFMT and include the limited availability of specialized therapists and financial or scheduling barriers. To address these barriers, we developed a novel online program delivering comprehensive long-term PFMT, pelvic floor education (PFE), and dietary/behavioral modification education. This study is a prospective interim analysis of online PFMT/PFE (oPFMT/PFE), with focus on feasibility, satisfaction, and continence outcomes.

Methods

Patients anticipating robotic-assisted laparoscopic prostatectomy (RALP) were recruited (6/2021-9/2022) for oPFMT/PFE. oPFMT/PFE comprises a 12-month program of 3 phases, including multiple exercises with varied contraction types and duration, and comprehensive dietary and behavioral technique education. Incontinence and quality of life (QOL) outcomes are assessed at 3 weeks, 3, 6, and 12 months following RALP using validated International Consultation on Incontinence Questionnaire Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) and Incontinence Impact Questionnaire (IIQ-7) questionnaires and additional items assessing satisfaction, improvement, and daily pad use. Primary study outcomes included ICIQ-MLUTS stress urinary incontinence (SUI) domain score (SDS) and SUI cure [ICIQ SUI domain score (SDS) =0]. Interim 6-month analysis was performed using mixed effects linear regression and mixed effects Poisson regression.

Results

Analysis included 21 men (64±6 years). At 6-month follow-up, men undergoing oPFMT/PFE showed significant improvement in SDS compared to the 3-week time point [mean ± standard error (SE) =1.05±0.24 vs. 0.45±0.17, P=0.011], but still experienced higher scores than at baseline (P=0.017). Six-month patient-reported improvement averaged 7.42±0.74 (10-point Likert scale). All (100%) of 19 respondents (2 missing data) found the program easy to use, educational, and would recommend it to others, with 89% expressing satisfaction with the program. During patient interview at 6-month follow-up, no men reported inability to access the program online or any adverse events. Finally, IIQ-7 score improved significantly from the 3-week timepoint (4.47±1.10) at both time points (3-month 1.14±0.44, P<0.001 and 6-month 1.10±0.37, P<0.001), and neither 3- nor 6-month scores differed from baseline (P=0.808 and P=0.444, respectively).

Conclusions

Our novel oPFMT/PFE yields significant improvements to validated urinary incontinence (UI) and QOL measures, providing a valuable and accessible treatment option for PPI.

Predictors of urinary outcomes following robotic-assisted laparoscopic prostatectomy

Introduction

Incontinence and urgency are common after prostatectomy. The University of Virginia prostatectomy functional outcomes program (PFOP) was developed to comprehensively assess and optimise continence outcomes following robotic-assisted laparoscopic prostatectomy (RALP). Patients are prospectively evaluated by a Female Pelvic Medicine and Reconstructive Surgery specialist. This study assessed for predictors of 3- and 6-month stress urinary incontinence (SUI) and urgency symptom outcomes following RALP.

Methods

We performed a post hoc review of patients from our PFOP receiving a minimum of 6-month follow-up. Urinary symptoms are prospectively assessed using the validated International Consultation on Incontinence Questionnaire-Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) questionnaire and daily pad use (pads per day [PPD]). Primary study outcomes included ICIQ-MLUTS SUI and urgency domain scores and PPD. Multivariable linear regression was performed to identify variables associated with outcomes at 3 and 6 months postoperatively. Variables included patient, oncologic and surgical factors. Each variable was run in a separate model with pelvic floor muscle therapy and surgeon to reduce confounding and prevent overfitting.

Results

Forty men were included. In assessment of ICIQ-MLUTS SUI domain score, at 3 months, body mass index (BMI) was associated with worse scores, and at 6 months, BMI, hypertension and estimated blood loss (EBL) were associated with worse scores, whereas bilateral nerve-sparing technique was associated with better scores. For ICIQ-MLUTS Urgency domain score, at 3 months, preoperative use of benign prostatic hyperplasia (BPH) medication was associated with better scores. No covariates predicted 6-month ICIQ-MLUTS Urgency domain scores. For PPD use, at both 3 and 6 months, BMI was a positive predictor, while preoperative use of BPH medication was a negative predictor.

Conclusion

Increased BMI, EBL and hypertension are associated with worsened SUI outcomes following RALP, whereas bilateral nerve-sparing technique and preoperative BPH medication are associated with improved SUI outcomes. These data may inform patient counselling and help identify patients who may benefit from closer surveillance and earlier anti-incontinence intervention.

Low-intensity shockwave therapy improves baseline erectile function: a randomized sham-controlled crossover trial

Background

Low-intensity shockwave therapy for erectile dysfunction is emerging as a promising treatment option.

Aim

This randomized sham-controlled crossover trial assessed the efficacy of low-intensity shockwave therapy in the treatment of erectile dysfunction.

Methods

Thirty-three participants with organic erectile dysfunction were enrolled and randomized to shockwave therapy (n = 17) or sham (n = 16). The sham group was allowed to cross over to receive shockwave therapy after 1 month.

Outcomes

Primary outcomes were the changes in Sexual Health Inventory for Men (SHIM) score and Erection Hardness Score at 1 month following shockwave therapy vs sham, and secondary outcomes were erectile function measurements at 1, 3, and 6 months following shockwave therapy.

Results

At 1 month, mean SHIM scores were significantly increased in the shockwave therapy arm as compared with the sham arm (+3.0 vs -0.7, P = .024). Participants at 6 months posttreatment (n = 33) showed a mean increase of 5.5 points vs baseline (P < .001), with 20 (54.6%) having an increase ≥5. Of the 25 men with an initial Erection Hardness Score <3, 68% improved to a score ≥3 at 6 months. When compared with baseline, the entire cohort demonstrated significant increases in erectile function outcomes at 1, 3, and 6 months after treatment.

Clinical Implications

In this randomized sham-controlled crossover trial, we showed that 54.6% of participants with organic erectile dysfunction met the minimal clinically important difference in SHIM scores after treatment with low-intensity shockwave therapy.

Strengths and Limitations

Strengths of this study include a sham-controlled group that crossed over to treatment. Limitations include a modest sample size at a single institution.

Conclusions

Low-intensity shockwave therapy improves erectile function in men with erectile dysfunction as compared with sham treatment, which persists even 6 months after treatment.

Clinical Trial Registration

ClinicalTrials.gov NCT04434352.

The impact of cognitive impairment in urologic implants: a narrative review

Background and Objective

With the general population aging and thus more patients developing bothersome erectile dysfunction, stress urinary incontinence and overactive bladder, there will likely be a higher demand for three common interactive implants in urology, the penile prosthesis, artificial urinary sphincter (AUS) and sacral neuromodulation (SNM). Further, the prevalence of mild and major neurocognitive disorders (also known as mild cognitive impairment and dementia, respectively) is expected to increase. While the aforementioned urologic implants have excellent short and long term outcomes, there are also known device issues such as malfunction or misuse that may require surgical removal and/or revision. The objective of this narrative review is to describe the association of cognitive impairment and urologic implants.

Methods

We performed a search on PubMed between the years 1975-2023 for English language articles that reported on any type or severity of cognitive impairment and its association with penile prosthesis, AUS and/or SNM. While peer-reviewed published manuscripts were prioritized, abstracts that fit our search criteria were also included.

Key Content and Findings

Data assessing outcomes of patients with cognitive impairment who undergo placement of a urologic implant are limited. There is an association between AUS failure or misuse with cognitive impairment. SNM is efficacious in this population in the short term. In patients who develop dementia, an inflatable penile prosthesis can be deflated via in-office needle puncture and an AUS can be deactivated. The Memory Alteration Test, Quick Screen for Mild Cognitive Impairment and the Saint Louis University Mental Status Examination are relatively quick screening tests with good sensitivity and specificity for mild cognitive impairment.

Conclusions

While data on the association between urologic implants and cognitive impairment are sparse, there are tools that urologists can use to screen patients for cognitive impairment. With screening, urologists can provide appropriate preoperative counseling (including recommending against implantation) and can provide closer postoperative monitoring. Further study is required to assess which patients should be excluded from device implantation and how to properly assess for cognitive impairment in a manner that is both beneficial for the patient and convenient and efficient for a urologist.

Comparison of In-person FPMRS-directed Pelvic Floor Therapy Program Versus Unsupervised Pelvic Floor Exercises Following Prostatectomy

OBJECTIVE

To compare comprehensive continence outcomes in patients receiving pelvic floor muscle training (PFMT) vs standard unsupervised home pelvic floor exercise therapy (UPFE).

METHODS

As part of the UVA prostatectomy functional outcomes program, participating patients complete a 12-month PFMT program under FPMRS specialist supervision. We performed a retrospective review of prospectively collected longitudinal outcomes in patients receiving PFMT vs UPFE through 12-month follow-up. Primary study outcome was ICIQ-MLUTS SUI domain score (SDS). Secondary outcomes included daily pad use (PPD), SUI Cure (SDS=0), and quality of life score (IIQ-7). Multilevel mixed effects linear regression was used to model SDS over time.

RESULTS

Analysis included 40 men. No difference in patient characteristics was seen in comparison of PFMT vs UPFE cohorts (P = NS, all comparisons). Mean predicted SDS was significantly better in the PFMT vs UPFE cohorts at 6-month (0.81 ± 0.21 vs 1.75 ± 0.34, respectively) (P = .014) and 12-month (0.72 ± 0.17 vs 1.67 ± 0.30, respectively) (P = .004) time points. At 12-month follow-up, 11 (55%) vs 4 (20%) patients reported absence of SUI in PFMT vs UPFE cohorts, respectively. Predicted probabilities of SUI cure in PFMT vs UPFE cohorts at 12months were 0.52 ± 0.14 vs 0.23 ± 0.13, respectively (P = .14). At 12-month follow-up, the mean predicted PPD and IIQ score was 0.19 ± 0.10 vs 0.79 ± 0.33 and 2.86 ± 0.86 vs 2.55 ± 1.07 in PFMT vs UPFE cohorts, respectively (P = NS).

CONCLUSION

In-person, FMPRS-directed PFMT is associated with improved SUI domain scores following robotic-assisted laparoscopic prostatectomy, a finding durable through 12-month follow-up.

Longitudinal urgency outcomes following robotic-assisted laparoscopic prostatectomy

PURPOSE

Stress urinary incontinence (SUI) is a well-known adverse outcome following robotic-assisted laparoscopic prostatectomy (RALP). Although postoperative SUI has been extensively studied, little focus has been placed on understanding the natural history and impact of urgency symptoms following RALP. The UVA prostatectomy functional outcomes program (PFOP) was developed to comprehensively assess and optimize continence outcomes following RALP. The present study focuses on assessing urgency outcomes in this cohort.

METHODS

PFOP patients with a minimum of 6-months follow up following RALP were included. The PFOP includes prospectively assessed incontinence and quality of life outcomes utilizing ICIQ-MLUTS, Urgency Perception Score (UPS), and IIQ-7 questionnaires. The primary study outcome was urgency urinary incontinence (UUI) as determined by ICIQ-MLUTS UUI domain. Secondary outcomes included urgency (UPS score) and quality of life (IIQ-7).

RESULTS

Forty patients were included with median age 63.5 years. Fourteen (35%) patients reported UUI at baseline. UUI and QOL scores worsened compared to baseline at all time-points. Urgency worsened at 3-weeks and 3-months but returned to baseline by 6-months. Notably, 63% of patients without baseline UUI reported de-novo UUI at 6 months. Although QOL was lower in patients with versus without UUI (IIQ-7 score 3.0 vs 0.0, p = 0.009), severity of UUI was not associated with QOL when controlling for SUI severity.

CONCLUSION

Our data demonstrate significantly worsened UUI from baseline and a large incidence of de-novo UUI following RALP. Further study is needed to inform how urgency and UUI and its treatment affect health-related quality of life following RALP.

Economic Impact of Urological Conditions in Men and Women in Belize

INTRODUCTION

Urological disease is prevalent in low- and middle-income countries. Concurrently, the inability to maintain employment or provide family care contributes to poverty. We assessed the microeconomic impacts of urological disease in Belize.

METHODS

We conducted a prospective survey-based assessment of patients evaluated during surgical trips by the charity Global Surgical Expedition. Patients completed a survey focusing on impact of urological disease on work and caretaker responsibilities, as well as its economic impact. The primary study outcome was income loss resulting from work impairment or work time missed related to urological disease. Income loss was calculated using the validated Work Productivity and Activity Impairment Questionnaire.

RESULTS

A total of 114 patients completed surveys. Overall, 87.7% and 37.2% of respondents reported a negative impact of urological disease on job and caretaking responsibilities, respectively. Nine (7.9%) patients were unemployed secondary to their urological disease. Sixty-one (53.5%) patients provided financial data sufficient for analysis. In this cohort, median weekly income was $250 Belize dollars (approximately $125 United States Dollars), while median weekly cost for urological disease treatment was $25 Belize dollars. Among the 21 (34.5%) patients who missed work due to urological disease, median weekly income loss was $35.6 Belize dollars, representing 55% of their total income. A vast majority (88.6%) of patients reported that cure of urological disease would increase ability to work and/or care for family.

CONCLUSIONS

In Belize, urological disease results in significant impairment of work and caretaking responsibilities, as well as income loss. Efforts are necessary to provide urological surgeries in low- and middle-income countries as urological disease impacts not only quality of life, but also financial health.

A narrative review of pelvic floor muscle training in the management of incontinence following prostate treatment

Background and Objective

Urinary incontinence following prostate treatment (IPT) is a common complication with corresponding negative impacts on quality of life. Pelvic floor muscle training (PFMT) is a non-invasive treatment strategy to treat combat this clinical issue, and has been recognized by medical associations globally and increasingly supported by large bodies of literature. Accordingly, many studies demonstrate a significant benefit of pelvic floor muscle training to continence status and quality of life in men with incontinence following prostate treatment. However, related research is limited by variety in treatment regimens, outcome measures, and study designs, with unclear impact on treatment success. We aim to provide a brief overview of pathology and incidence of incontinence following prostate surgery and an understanding how PFMT is currently used to treat and prevent this clinical consequence.

Methods

A comprehensive literature search was conducted utilizing PubMed, Medline, and Google Scholar. Search criteria included systematic reviews and randomized control trials published in the year 2000 to present. References of resulting studies were further analyzed to identify further articles of relevance. Keywords searched included: “post-prostatectomy incontinence”, “pelvic muscle strengthening”, “Benign Prostatic Hyperplasia”, and “pelvic floor muscle training”. Peer-reviewed publications that demonstrated a novel addition to the existing body of literature on this subject were included.

Key Content and Findings

Upon review of the current research landscape, PFMT is largely supported in treatment of IPT. Analysis of current literature on this subject demonstrates heterogeneity in protocols, measures of treatment success, and patient numbers. Nevertheless, benefits to continence and quality of life are noted across an expansive body of literature and as such, PFMT is therefore recommended as an important part of the treatment algorithm following radical prostatectomy.

Conclusions

PFMT is an important and effective part of the treatment algorithm in the prevention and treatment of IPT. Additional research is needed to more extensively assess PFMT’s role in treating this clinical consequence, especially following other prostate surgeries.

Prevalence and characterization of dyspareunia in a general urology clinic population

INTRODUCTION

To assess the character and prevalence of dyspareunia in a general urology population presenting for evaluation of unrelated non-painful complaints.

MATERIALS AND METHODS

This is an IRB-approved, prospective, cross-sectional survey-based assessment of dyspareunia in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints were excluded. Participating patients completed an original 23-item survey with questions pertaining to dyspareunia. Specific focus was placed on pain characteristics, including location, quality, frequency, severity, and quality of life. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns.

RESULTS

A total of 181 women completed the survey, with a mean age of 56 years. Overall, 53 (29%) women reported dyspareunia. However, among currently sexually active women the prevalence of dyspareunia was 46% (38/83). Patients reported a significant variety of pain locations and qualities. Women most commonly reported multiple pain locations (median 2 (IQR 1,4)), with 33 distinct combinations identified. The majority (70%) of women endorsed only one pain quality, although eight unique combinations were nonetheless seen. A significant proportion (34%) reported high or very high pain severity, with 45% having pain most or all times of sexual activity. A majority (53%) of patients indicated moderate to severe dissatisfaction with their sexual activity. Despite this finding, a significant proportion (33%) of patients with dyspareunia reported having at least weekly sexual activity.

CONCLUSIONS

A significant percentage of women presenting to a general urology clinic experience dyspareunia. Notably, patient-reported pain characteristics, including location and quality, varied significantly across women assessed. Further study is needed to understand how these characteristics may relate to different and specific etiologies of sexual pain and directed treatment options.

Analysis of Online Urologist Ratings: Are Rating Differences Associated With Subspecialty?

Patients are increasingly using online rating websites to obtain information about physicians and to provide feedback. We performed an analysis of urologist online ratings, with specific focus on the relationship between overall rating and urologist subspecialty. We conducted an analysis of urologist ratings on Healthgrades.com. Ratings were sampled across 4 US geographical regions, with focus across 3 practice types (large and small private practice, academic) and 7 urologic subspecialties. Statistical analysis was performed to assess for differences among subgroup ratings. Data were analyzed for 954 urologists with a mean age of 53 (±10) years. The median overall urologist rating was 4.0 [3.4-4.7]. Providers in an academic practice type or robotics/oncology subspecialty had statistically significantly higher ratings when compared to other practice settings or subspecialties (P < 0.001). All other comparisons between practice types, specialties, regions, and sexes failed to demonstrate statistically significant differences. In our study of online urologist ratings, robotics/oncology subspecialty and academic practice setting were associated with higher overall ratings. Further study is needed to assess reasons underlying this difference.

Prevalence of Cognitive Impairment and Sphincter Misuse Among Men With Artificial Urinary Sphincters

OBJECTIVES

To define the prevalence of cognitive impairment and sphincter misuse among men who had undergone AUS placement.

METHODS

Men who had previously undergone AUS placement from 2004 to 2019 were assessed through comprehensive telephone surveys. The primary survey outcome was cognitive function, assessed via validated Telephone Mini-Mental State Examination. Secondary survey outcomes included rate of AUS misuse, surgical outcomes, and overall device satisfaction. Statistical analysis was performed to assess for differences between patients with and without cognitive impairment.

RESULTS

A total of 74 patients participated, with a mean age and follow-up of 75 and 7.8 years, respectively. Telephone Mini-Mental State Examination assessment revealed cognitive impairment in 18 (24%) patients, 13 (18%) with mild-moderate and 5 (7%) with severe impairment. Overall, 23 (31%) and 11 (15%) patients reported inconsistent use (not cycling AUS with every void) and device neglect, respectively. Patients with impaired cognition were more likely to report difficulty with AUS use compared to those with normal cognition (39% vs 9%, P= .01). There was no difference seen in rates of revision, rates of retention, or urinary tract infections between cognitive groups.

CONCLUSIONS

Our study revealed significant rates of cognitive impairment and sphincter misuse among men with AUS. These data suggest a role for long-term follow-up and monitoring for cognitive changes. Prospective study of cognitive decline and surgical outcomes in patients undergoing AUS is warranted.

Trends in Female Authorship Within Urologic Literature: A Comparison of 2012 and 2017

OBJECTIVE

To evaluate trends in female authorship in the recent urologic literature.

METHODS

We examined articles published in 2012 and 2017 from 5 urologic journals: Journal of Urology, Journal of Endourology, Neurourology and Urodynamics, Urologic Oncology, and Urology. Gender was recorded for first, supplemental, and last authors. Articles were further categorized by subspecialty focus of the published article. Chi-square tests and multiple logistic regression modeling were used to assess for differences in female authorship by year, journal, and article subspecialty.

RESULTS

One thousand four hundred and thirty-three and 1374 articles were published in 2012 and 2017, respectively. There was a significant increase in all female authorship categories between years: first (19%-25%), last (12-16%), and any (67%-74%) (P<.01, all). By journal, the highest proportion of articles with any female authors for both years was in Neurourology and Urodynamics (80%, 2012; 85%, 2017) while lowest was in Journal of Endourology (49%, 2012; 54%, 2017). Likewise, female authorship was generally higher in female/voiding dysfunction /incontinence and lower in endourology subspecialty articles. Controlling for journal and subspecialty, multiple logistic regression analysis showed no change in last authorship between years.

CONCLUSION

Overall female authorship in the urologic literature has increased in recent years. However, after controlling for journal and subspecialty we found no increase in female last authorship between years, suggesting that disparities in senior authorships exist based on journal and subspecialty topic. Our findings further suggest an authorship plateau, highlighting the importance of efforts to optimize advancement and promotion of women in academic urology.

Characterization and Prevalence of Female Pelvic Pain in a General Outpatient Urology Population

OBJECTIVE

To assess the character and prevalence of female pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints.

METHODS

This is an IRB-approved, prospective, cross-sectional survey-based assessment of pelvic pain in a general cohort of female patients presenting to a urology clinic over a 10-month period (7/2018-5/2019). Patients presenting specifically for acute painful complaints (eg, kidney stones) were excluded. Participating patients completed an original 22-item survey with questions pertaining to pelvic pain. Specific focus was placed on pain characteristics, including location, quality, frequency, exacerbating factors, and severity. Descriptive analysis, pain mapping, and plotting analyses were performed to assess pain patterns.

RESULTS

A total of 181 women (mean age 56 years) completed the survey. Overall, 75 (41%) women reported pelvic pain. Two-thirds reported experiencing pain "often" to "always" over the preceding month. Patients described a significant variety of pain locations and qualities. The most common sites of pain were lower back (73%) and bladder (72%), while "dull/aching" was the most common pain quality. A majority (84%) of patients had multiple concurrent pain locations, with 40 unique pain location combinations being reported. Similarly, 13 and 10 unique combinations were seen with pain quality and eliciting activity, respectively.

CONCLUSION

A significant percentage of women presenting to a general urology clinic experience pelvic pain. There was wide variety of pain characteristics and unique patterns. Further research is needed to comprehensively assess pain characteristics and develop related diagnostic pathways.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS

To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI.

METHODS

We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT.

RESULTS

Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (β coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057).

CONCLUSIONS

Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

Urinary Incontinence Research: Compliance With Research Standards for Clinical Studies

OBJECTIVE

To perform an updated literature review to assess compliance with outcomes use and reporting guidelines. In 1997, the Urodynamics Society recommended standards of efficacy to be used for evaluation of treatment outcomes in urinary incontinence (UI). Studies published shortly after the release of these standards reported generally low rates of adherence.

METHODS

We reviewed all 2017 articles related to UI in 3 urologic journals (Journal of Urology [JU], Neurourology and Urodynamics [NU], and Urology [UR]). Articles were assessed for compliance with 19 standards across 3 categories (methodology, pretreatment, and post-treatment). Analysis focused on overall and category specific compliance, as well as comparison of compliance between journals.

RESULTS

A total of 78 articles met inclusion criteria for analysis. The mean overall compliance was 52% for all standards. JU demonstrated a higher compliance (63%) as compared to NU (50%) and UR (46%) (P <.01). No articles reviewed demonstrated 100% compliance with all standards. Only 23%, 6%, and 12% of JU, NU, and UR articles, respectively, demonstrated at least 75% compliance with all standards. In comparison of subcategory compliance, JU demonstrated a statistically higher methodology compliance (P <.01). In contrast, compliance with both pre- and post-treatment standards across all 3 journals demonstrated no statistically significant differences.

CONCLUSION

Overall, we found that a significant percentage of recent study on UI fails to meet suggested standards for use and reporting of outcomes. These data suggest that continued efforts are needed to improve the quality and reporting of UI research.

Effect of body mass index on recurrence following urethroplasty

Background

Limited investigation exists to understand whether obesity affects outcomes of urethral reconstruction. We sought to assess whether body mass index (BMI) is an independent predictor for stricture recurrence following urethroplasty.

Methods

We performed a retrospective review of patients undergoing urethroplasty between 2007–2014, identifying 137 patients for study inclusion. Data collected included BMI and patient demographic and surgical characteristics, including age, stricture length and location, etiology, and urethroplasty technique. Stricture-free survival analysis was performed using Kaplan-Meier method. Logistic regression was performed to assess predictors for stricture recurrence using both univariate and multivariate models.

Results

Mean patient age and follow-up was 46.7 (±16.4) years and 91.8 (±30.5) months, respectively. A recurrence rate of 17% was identified, with a mean time to recurrence of 29 months. There was no difference when comparing the mean BMI in patients with and without recurrence (28.9 vs. 30.4 kg/m², respectively) (P=0.4). A higher rate of stricture recurrence was seen when comparing the cohort with a BMI <25 kg/m² versus remaining cohorts (BMI: 25–30 kg/m²; BMI >30 kg/m²). However, in univariate and multivariate analysis, BMI failed to demonstrate statistical significance as a predictor for urethroplasty outcome. On multivariate analysis, fasciocutaneous repair type was predictive of stricture recurrence. No additional potential predictors assessed were found to be significant.

Conclusions

In the present study, BMI did not independently predict for stricture recurrence following urethroplasty.

Assessment of communication technology and post-operative telephone surveillance during global urology mission

Objective

Compliance with post-operative follow-up in the context of international surgical trips is often poor. The etiology of this problem is multifactorial and includes lack of local physician involvement, transportation costs, and work responsibilities. We aimed to better understand availability of communication technologies within Belize and use this information to improve follow-up after visiting surgical trips to a public hospital in Belize City. Accordingly, a 6-item questionnaire assessing access to communication technologies was completed by all patients undergoing evaluation by a visiting surgical team in 2014. Based on this data, a pilot program for patients undergoing surgery was instituted for subsequent missions (2015–2016) that included a 6-week post-operative telephone interview with a visiting physician located in the United States.

Results

Fifty-four (n = 54) patients were assessed via survey with 89% responding that they had a mobile phone. Patients reported less access to home internet (59%), local internet (52%), and email (48%). Of 35 surgical patients undergoing surgery during 2 subsequent surgical trips, 18 (51%) were compliant with telephone interview at 6-week follow-up. Issues were identified in 3 (17%) patients that allowed for physician assistance. The cost per patient interview was $10 USD.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3256-2) contains supplementary material, which is available to authorized users.

Providing Access to Care through a 24-Hour Dedicated Stone Line

INTRODUCTION

Many patients with urolithiasis are seen acutely in the emergency department for initial treatment. In an effort to improve cost and quality of care increasing focus has been placed on shifting management of low acuity conditions from emergency departments to outpatient settings. One barrier to such initiatives is timely access to outpatient services. We established a telephone stone line to provide access to outpatient urological care of kidney stones and we report our initial experience.

METHODS

A 24-hour dedicated telephone stone line was created with calls answered by dedicated staff. A computer program was created to track stone line calls and post-call care. We retrospectively analyzed all stone line calls received in a 4-year period with the focus on utilization and cost. An e-mail survey was performed to assess patient satisfaction.

RESULTS

Between January 2009 and July 2013 the mean call volume was 2,107 per year. A significant distribution of calls was seen across all days and hours. Duration was less than 15 minutes in 7,761 calls (82%). Patients or family members placed 77% of calls and physicians placed 16%. As a result of a stone line call, 4,173 patients (76%) were seen by a urologist within 48 hours. Of the patients 88% reported satisfaction with the stone line. The mean annual cost of providing the telephone stone line was $51,873.

CONCLUSIONS

Our experience demonstrates sustained utilization of and satisfaction with the telephone stone line. Further, stone line use results in timely outpatient evaluation in the majority of patients. Further analysis to assess for a cost benefit is ongoing.

Clinical variables and stone detection in patients with flank pain

INTRODUCTION

Non-contrast CT (NCT) is commonly used to evaluate flank pain (FP). We sought to evaluate incidence of ureteral calculi on NCT in patients with FP, and to determine if clinical variables are associated with higher detection rates.

MATERIALS AND METHODS

Retrospective review identified 613 patients undergoing NCT for FP. Patient clinical data, NCT findings, and intervention were analyzed. Focus was placed on variables commonly associated with urolithiasis (Vstone), comprising hematuria, nausea/vomiting, and prior stone history. Statistical analysis was performed to identify risk of ureteral stones based on number and type of Vstone.

RESULTS

No stone disease was identified on NCT in 175 patients (28.5%). NCT demonstrated 214 (35%), 72 (12%), and 152 (25%) patients with stones located in the kidney, ureter, or both, respectively. Only 33 (5%) patients had FP as their sole Vstone, with ureteral calculi identified in 6% of this cohort. The rate of ureteral calculi increased with more Vstone. Patients having all four Vstone were found to have the highest rate of ureteral stones (59%). Statistical analysis demonstrated a statistically significantly increased relative risk of stone formation given three or four Vstone when compared with FP alone.

CONCLUSIONS

Whereas isolated FP is associated with a lower rate of ureteral calculus detection, a significant increased relative risk of ureteral calculus is seen in patients with additional clinical variables associated with stone disease. Accordingly, it may be possible to improve detection rates of ureteral stones through the use of additional clinical variables to guide NCT selection.

The male suburethral sling: remaining questions

The AdVance transobturator sling represents an important treatment option for male stress urinary incontinence. Accordingly, recent data suggests AdVance to yield success rates of 62%-77% through 3 year follow up.1,2 Although experience to date is favorable, many questions exist. Foremost, the ideal technique for intraoperative placement and tensioning remains a topic of discussion. The exact mechanism by which sling placement restores continence is unknown, but is hypothesized to comprise an elevation of the bulbar urethra both ventrally and cranially. This "repositioning" may then lead to improved urethral coaptation. Concurrently, urodynamic investigation suggests that sling action does not involve an obstructive effect.3 Despite these findings, other investigation highlights the questions that remain regarding sling mechanism of action and the role that urethral compression may place in continence restoration. Accordingly, study of postoperative MRI findings suggests that urethral bulb indentation may be associated with postoperative continence.4 Further, acute urinary retention (AUR) is frequently observed following sling placement, seen in 12%-21% of cases.2,5 Although it is hypothesized that the high rate of AUR may relate to a detrusor muscle deconditioned during prolonged periods of low outlet resistance, a role of urethral compression cannot be excluded. The authors seek to investigate the hypothesis that postoperative AUR may actually be associated with improved continence outcomes. The authors identify continence rates of 100% and 26% in comparison of patients experiencing postoperative AUR versus patients undergoing successful void trial, respectively.6 While this finding is of value, several issues are important to mention. Foremost, additional research is needed to confirm the primary study finding given that prior multivariate analysis has demonstrated that AUR presence/absence was not an independent risk factor for sling failure.7 Second, given some data suggesting that sling success rates deteriorate over time, longitudinal long term investigation is important to determine whether postoperative AUR may be a predictor for durable success rates.8 Finally, assessment of urgency outcomes following male sling placement is important. De novo irritative symptoms and voiding dysfunction following midurethral sling placement in women are a significant concern. Such adverse effects are thought to arise due to an obstructive or irritative effect of the sling. Although the mechanism of action of the AdVance sling is likely different, data regarding urgency outcomes is nonetheless important. This is especially true of patients experiencing AUR postoperatively, even if transient. Despite the many questions that remain, the primary study finding of improved outcomes in patients experiencing AUR is important. Anecdotally, I have observed this tendency in my own practice and believe this to be an observation warranting investigation.

Association of bladder sensation measures and bladder diary in patients with urinary incontinence

INTRODUCTION

Investigation suggests the involvement of afferent actions in the pathophysiology of urinary incontinence. Current diagnostic modalities do not allow for the accurate identification of sensory dysfunction. We previously reported urodynamic derivatives that may be useful in assessing bladder sensation. We sought to further investigate these derivatives by assessing for a relationship with 3-day bladder diary.

MATERIALS AND METHODS

Subset analysis was performed in patients without stress urinary incontinence (SUI) attempting to isolate patients with urgency symptoms.

RESULTS

No association was demonstrated between bladder diary parameters and urodynamic derivatives (r coefficient range (-0.06 to 0.08)(p > 0.05)). However, subset analysis demonstrated an association between detrusor overactivity (DO) and bladder urgency velocity (BUV), with a lower BUV identified in patients without DO. Subset analysis of patients with isolated urgency/urge incontinence identified weak associations between voiding frequency and FSR (r = 0.39) and between daily incontinence episodes and BUV (r = 0.35). However, these associations failed to demonstrate statistical significance.

CONCLUSIONS

No statistical association was seen between bladder diary and urodynamic derivatives. This is not unexpected, given that bladder diary parameters may reflect numerous pathologies including not only sensory dysfunction but also SUI and DO. However, weak associations were identified in patients without SUI and, further, a statistical relationship between DO and BUV was seen. Additional research is needed to assess the utility of FSR/BUV in characterizing sensory dysfunction, especially in patients without concurrent pathology (e.g. SUI, DO).

Short term urgency outcomes following transobturator midurethral sling placement

INTRODUCTION

Research suggests that midurethral sling placement may have a beneficial effect on urgency (U) and urge incontinence (UUI). This study examined short term U/UUI outcomes in patients undergoing TVT-O placement.

METHODS

One hundred patients undergoing TVT-O placement were prospectively assessed using 3 day bladder diary, combined with multiple validated incontinence questionnaires focusing on UUI, U and QoL.

RESULTS

At 6 week assessment, improvements in daily pad use (2.6 to 0.9) and incontinence episodes (3.6 to 0.7) were seen (p < 0.05, both comparisons). Eighty-two patients reported cure of stress incontinence. Focused outcome scores for UUI improved from 2.0 (± 1.1) to 0.8 (± 1.0) (p value < 0.001), with 39% and 29% of patients reporting score resolution and improvement, respectively. Similarly, mean Urinary Perception Score improved from 10.1 (± 4.4) to 5.8 (± 3.7) (p value < 0.001) with cure/improvement identified in 75%. Eighty-four patients did not require anticholinergics postoperatively. Interestingly, patients reporting residual SUI but improved UUI demonstrated QoL scores only slightly worse than patients with SUI cure and improved or persistent UUI.

CONCLUSION

TVT-O placement is associated with cure/improvement in a significant proportion of patients. In addition, significant improvement in QoL is seen following TVT-O placement.

Prolonged urinary retention after intravesical botulinum injection for treatment of idiopathic detrusor overactivity

INTRODUCTION

Botulinum toxin (BTX) has emerged as a treatment of refractory overactive bladder (OAB) and, while well tolerated, there exists concern regarding postoperative urinary retention.

CASE

A 75-year-old female underwent intravesical BTX-A injection, which was followed by a prolonged episode of urinary retention, highlighting an unusual duration and degree of UR associated with BTX-A injection in the treatment of idiopathic detrusor overactivity (IDO). This case illustrates clinically significant urinary retention with bladder diaries demonstrating persistent postvoid residual (PVR) measurements exceeding voided volume until 9 month follow up.

CONCLUSIONS

Notably, this duration and severity of urinary retention remains rare. However, this case underscores the need to appropriately counsel patients regarding the risks associated with intravesical injection of BTX-A.

Defining success following sling surgery: association of satisfaction with patient reported outcomes

AIMS

The assessment of incontinence therapies is complicated by the variety of patient reported outcomes (PRO) measures used in research protocol. Patient satisfaction may be one of the most relevant albeit complex PRO measures and is a function of many related variables. We sought to assess the relationship between patient satisfaction and other PRO.

METHODS

A retrospective review of patients undergoing SPARC (n = 314) and autologous rectus pubovaginal sling (PVS) (n = 127) was performed, with 204 (SPARC) and 67 (PVS) patients completing questionnaire surveillance and minimum 12 month follow up. Outcomes were assessed using validated incontinence questionnaires (UDI-6, IIQ-7) supplemented with additional items addressing subjective improvement. Comparisons were made between patients reporting a willingness to recommend and repeat surgical intervention (combined variable, satisfaction surrogate) and achievement of defined endpoints in the remaining outcome measures.

RESULTS

A large difference in outcomes was seen depending on PRO measure analyzed. Dry was the strictest measure used (33%, SPARC; 39%, PVS; p = NS), while >or= 50% improvement was reported with the greatest frequency (75%, SPARC; 73%, PVS; p = NS). With the exception of pad use, a statistically significant association between all PRO measures and the willingness to recommend/repeat surgery was identified.

CONCLUSIONS

Our data demonstrate an association between a variety of PRO measures and patient reported satisfaction. Based on this finding, the development of a simplified and standardized PRO instrument, one that maintains an accurate reflection of patient satisfaction and is less cumbersome for the patient may be possible.

Recutting prostate needle core biopsies with high grade prostatic intraepithelial neoplasia increases detection of adenocarcinoma

OBJECTIVES

We sought to evaluate the ability of biopsy core recutting to increase cancer detection in patients with high grade prostatic intraepithelial neoplasia (HGPIN).

METHODS

This prospective study encompasses all patients undergoing 12 core TRUS guided prostate biopsy between February 2004 and January 2007. In patients with HGPIN on initial biopsy, the paraffin blocks were resampled for cancer by additional deeper levels per core. Additional analysis was performed in the patients with HGPIN in order to detect whether significant differences in prebiopsy variables were associated with patients subsequently found to have benign versus carcinoma on recutting. Last, the costs associated with this procedure were studied.

RESULTS

Forty of 584 (6.8%) patients undergoing prostate biopsy were found to have HGPIN in the absence of prostatic adenocarcinoma on initial histopathology. Following recutting, 12.5% (5/40) of these patients were found to have prostatic adenocarcinoma not previously detected. Of the remaining 35 patients, 18 underwent repeat biopsy. Of these, five patients were found to have adenocarcinoma and three were found to have persistent HGPIN. The PSA, PSA density (PSAD), and PSA velocity (PSAV) prior to initial biopsy were not statistically different when comparing patients found to have benign tissue versus carcinoma on recutting. In patients with HGPIN, at our institution, recutting the biopsy would yield a cost savings of $436/patient as opposed to universal rebiopsy.

CONCLUSIONS

Our data suggest that prostate biopsy recutting may increase cancer detection in patients initially found to have HGPIN. Additionally, a significant cost savings is associated with the recutting protocol.

High intensity focused ultrasound renal tissue ablation: a laparoscopic porcine model

PURPOSE

High intensity focused ultrasound for renal lesions is still experimental. In a porcine model we evaluated the safety and efficacy of a newly designed laparoscopic high intensity focused ultrasound probe and software that allows real-time ultrasound guidance during renal tissue ablation.

MATERIALS AND METHODS

A Sonatherm 600 high intensity focused ultrasound system with a newly designed laparoscopic high intensity focused ultrasound probe was used through a standard Endopath 18 mm port. A total of 16 lesions were created in 15 kidneys in a total of 8 animals and randomized into 2 groups, including acute with sacrifice 4 days postoperatively and subacute with sacrifice 14 days postoperatively. Lesion size and location varied for each surgical procedure to simulate various treatment scenarios.

RESULTS

Mean +/- SD planned ablation volume was 7.1 +/- 5.1 cc and mean treatment time was 7.2 +/- 06.88 minutes. For all lesions an injury volume was observed with a central zone of complete necrosis and no viable tissue. Mean total injury volume was 6.5 + 3.5 cc (range 1.1 to 13.7), comparable to preoperative mean planned ablation volume (p = 0.84). Mean necrosis volume was 4.89 +/- 2.9 cc (range 0.8 to 10.5), appreciably lower than preoperative mean planned ablation volume (p = 0.33). Presence of the collecting system interposed with the treatment region did not impact the injury volume-to-planned ablation volume ratio or the necrosis volume-to-planned ablation volume ratio. No animals died before study completion. Two intraoperative complications occurred, including a back wall musculature burn and a ureteral burn.

CONCLUSIONS

Laparoscopic high intensity focused ultrasound for renal tissue using the newly developed probe was feasible and efficacious. The ability to perform renal high intensity focused ultrasound through an 18 mm laparoscopic port offers a new alternative for renal tumor ablation.

The use of botulinum toxin for treatment of lower urinary tract symptoms

In the last decade we have seen the emergence of botulinum toxin (BTX) as a successful treatment of patients with neurogenic and idiopathic detrusor overactivity that are refractory to antimuscarinic medication. The success of BTX in this patient population has led to use BTX in patients with other causes of lower urinary tract symptoms such as benign prostatic hyperplasia (BPH) and urethral sphincter anomalies. Despite this success, the protocol for BTX injection has not yet been standardized. Various studies are on the way in order to determine the best injection protocol for bladder injection of BTX. The use of BTX in patients with BPH is in its early stages. Further large randomized controls trials in patients with BPH are needed to determine the efficacy of BTX in this patient population.