British Association of Urological Surgeons Consensus statements on the management of ketamine uropathy.

OBJECTIVES: To provide guidance in the form of consensus statement in the management of ketamine uropathy. METHODS: A literature review of ketamine uropathy was performed. The consensus method was of a modified nominal group technique and has been use in the previous British Association of Urological Surgeons (BAUS) consensus documents and was led by the Female, Neurological and Urodynamic Urology Section of the BAUS. RESULTS: A number of consensus statements detailing the assessment and management of urological complications relate to the recreational use of ketamine (ketamine uropathy) in both elective and emergency urology settings. CONCLUSION: Comprehensive management pathway for ketamine-related urinary tract dysfunction and uropathy has been detailed.

Robotic sacrocolpopexy with medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman.

Vaginoplasty is commonly performed to treat gender dysphoria in transgender women. Neovaginal prolapse is a late complication of vaginoplasty, and there is minimal literature regarding its surgical management. We report a case of robotic sacrocolpopexy using medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman, which is a novel technique that has not been previously described. The procedure resulted in a good postoperative outcome for the patient. The innovative use of medial umbilical ligament autologous graft enabled the patient to benefit from a fully minimally invasive procedure whilst avoiding the risks associated with synthetic mesh.

Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review.

Background: Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS. Results: After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general. Discussion: The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.

Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review.

CONTEXT: Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice. OBJECTIVE: To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS). EVIDENCE ACQUISITION: We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported. EVIDENCE SYNTHESIS: The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development. CONCLUSIONS: Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes. PATIENT SUMMARY: Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.

Pre-Clinical Evaluation of Tenofovir and Tenofovir Alafenamide for HIV-1 Pre-Exposure Prophylaxis in Foreskin Tissue.

BACKGROUND: HIV-1 pre-exposure prophylaxis (PrEP) has focused predominantly on protective efficacy in receptive sex, with limited research on the dosing requirements for insertive sex. We pre-clinically assessed the ex vivo pharmacokinetic-pharmacodynamic (PK-PD) profile of tenofovir (TFV) and tenofovir alafenamide (TAF) in foreskin tissue. METHODS: Inner and outer foreskin explants were exposed to serial dilutions of TFV or TAF prior to addition of HIV-1BaL at a high (HVT) or a low viral titer (LVT). Infection was assessed by measurement of p24 in foreskin culture supernatants. TFV, TAF and TFV-diphosphate (TFV-DP) concentrations were measured in tissues, culture supernatants and dosing and washing solutions. RESULTS: Dose-response curves were obtained for both drugs, with greater potency observed against LVT. Inhibitory equivalency mimicking oral dosing was defined between 1 mg/mL of TFV and 15 µg/mL of TAF against HVT challenge. Concentrations of TFV-DP in foreskin explants were approximately six-fold higher after ex vivo dosing with TAF than with TFV. Statistically significant negative linear correlations were observed between explant levels of TFV or TFV-DP and p24 concentrations following HVT. CONCLUSIONS: Pre-clinical evaluation of TAF in foreskin explants revealed greater potency than TFV against penile HIV transmission. Clinical evaluation is underway to support this finding.

Prostate cancer in transgender women: what does a urologist need to know?

OBJECTIVE: To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs. MATERIALS AND METHODS: We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women. RESULTS: Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women. CONCLUSION: The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

Genital Reconstructive Surgery in Male to Female Transgender Patients: A Systematic Review of Primary Surgical Techniques, Complication Profiles, and Functional Outcomes from 1950 to Present Day.

CONTEXT: Genital reconstructive surgery (GRS) is a necessary part of transitioning for many transwomen, and there is evidence of positive effects on a person's well-being and sexual function. Surgical techniques have evolved, from pursuing aesthetic outcome to now functional outcome with natal females as the standard. OBJECTIVE: To systematically review the evidence, identifying the surgical techniques used in primary GRS, their complications, functional outcomes, and the tools used to assess them. EVIDENCE ACQUISITION: The clinical question was designed using the standard PICOS format. The search complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 statement and was performed by two independent reviewers. EVIDENCE SYNTHESIS: Europe, USA, and Thailand favour the penoscrotal technique for vaginoplasty, whereas in the UK, the penile inversion (PI) technique predominates. Primary vaginoplasty using a segment of bowel is less common, and all three techniques have comparable rates of intraoperative rectal injury. The incidence of rectovaginal fistula is reportedly higher in the PI technique. Wound haematoma and vaginal prolapse rates are comparable. Higher rates of clitoral necrosis, urethral meatal stenosis, and wound infection are reported in PI. However, the ability to orgasm, ability to have penetrative sexual intercourse, and satisfaction with aesthetic result are better with PI. CONCLUSIONS: The evidence for GRS complications and functional outcomes is of low level. Standardised nomenclature reporting of adverse events and robust patient-reported outcome measures (PROMs) are lacking. PROMs are a powerful assessment tool, and standardised definitions of adverse events and functional outcomes should be a priority of future research. PATIENT SUMMARY: We looked at all studies published on genital reconstructive surgery from 1950 to the present day. We assessed each surgical technique and their associated complication rates, sexual and urinary function outcomes, and how they were reported. We found the evidence to be low and weak. We suggest more robust ways of reporting complications, and the impact on patients' quality of life should be investigated.

A very rare case of delayed catastrophic arterial bleed post-vaginoplasty.

The gold standard for male to female genital reconstruction in the UK is vaginoplasty with penile and/or scrotal skin for neovagina formation. We present a rare case of a major haemorrhage in a 46-year-old patient, 26 days post-vaginoplasty. An urgent computed tomography scan identified a large retrovesical collection, with high-density contents in keeping with recent haemorrhage, containing a 6mm pseudoaneurysm within the right lateral wall. Following resuscitation, the patient was urgently treated with successful embolization of the feeding artery (branch of the prostatic artery), with pushable coils. We highlight the importance of expedient, life-saving management in a rare post-operative complication.

The Role of Urinary Microbiota in Lower Urinary Tract Dysfunction: A Systematic Review.

CONTEXT: Until 2012, the urinary tract of healthy individuals was considered to be sterile. The advent of metagenomic sequencing revealed a unique urinary microbiota (UM). This paradigm shift appears to have prolific implications in the etiology of several functional lower urinary tract (LUT) disorders. OBJECTIVE: To systematically summarize recent data on the role of UM in LUT dysfunction. EVIDENCE ACQUISITION: We performed a critical review according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. We conducted a search on PubMed/MEDLINE and SCOPUS with the following MESH terms/keywords: "Microbiome OR Microbiota AND (urinary disorder OR urinary tract symptom OR overactive bladder OR urinary incontinence OR interstitial cystitis OR chronic prostatitis)." The range of search was placed between January 2010 and April 2018, and articles with no full text available or those not written in English were excluded. All retrieved papers were first reviewed by title and abstract, yielding a total of 303 papers. Additional manuscripts, such as those referenced by reviews, were further included. Thirty-six publications were included. EVIDENCE SYNTHESIS: Analysis by 16S rRNA sequence and expanded quantitative urine culture provided evidence for the presence of live bacteria in urine, nondetectable by standard culture protocols. Moreover, differences in the UM between healthy individuals and patients with LUT dysfunction were demonstrated. CONCLUSIONS: In the near future, urologists must consider urinary dysbiosis as a possible cause of different functional LUT disorders, with potential clinical implications in their diagnosis and treatment. PATIENT SUMMARY: Development of metagenomic sequencing revealed a unique urinary microbiota nondetectable by standard culture protocols. This systematic review summarizing recent data on the role of urinary microbiota in lower urinary tract (LUT) dysfunction supports urinary dysbiosis as a possible cause of different functional LUT disorders.

Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM).

BACKGROUND: Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies). OBJECTIVE: To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included. DESIGN, SETTING, AND PARTICIPANTS: A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments. INTERVENTION: Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient. RESULTS AND LIMITATIONS: Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure. CONCLUSIONS: Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function. PATIENT SUMMARY: We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.

Post-prostatectomy incontinence: multimodal modern-day management.

As the rate of prostate cancer detection increases, so does the rate at which radical prostatectomy is performed. Post-prostatectomy incontinence (PPI) or urine leakage affects around 20% of men who undergo this procedure. Although affected individuals must be supported in maintaining hygiene with the use of urine capture devices, definitive treatment should also be offered if appropriate. A range of management options are available, from incontinence pads to artificial urinary sphincters. However, an understanding of the aetiology of the leak as well as patient factors is vital if the correct treatment option is to be selected. This article describes the potential causes of PPI and explores management options for this condition.

Oral Pharmacologic Management of Overactive Bladder Syndrome: Where Do We Stand?

Overactive bladder syndrome (OAB) is a prevalent disorder with a significant impact on quality of life. Despite this high prevalence, there is significant underdiagnosis and undertreatment due to several barriers, including embarrassment, poor communication and low patient adherence. Currently, various antimuscarinic are available in the treatment of OAB. The introduction of mirabegron has broadened the therapeutic approach and combination therapy of both agents can be valuable in clinical practice. Yet, patient adherence to most drugs for OAB is still relatively poor. Healthcare providers need to identify and utilise strategies to improve treatment adherence by defining clear treatment goals, implement educational methods and frequently communicate with patients to identify problems with adherence. The elderly population form need special attention as in these patients, anticholinergics should be prescribed with care and adequate knowledge regarding pharmacokinetics and drug interactions in essential. Furthermore, patient expectations should be clearly discussed. In this narrative review, the current advances in oral pharmacotherapy are evaluated and the most important factors involved in the management of OAB are discussed.

Management of Idiopathic Overactive Bladder Syndrome: What Is the Optimal Strategy After Failure of Conservative Treatment?

CONTEXT: A considerable number of patients affected by the overactive bladder syndrome (OAB) do not respond to pharmacotherapy and bladder training due to unsatisfactory response or intolerability. OBJECTIVE: To review the available literature assessing therapeutic effect of the available third-line treatment modalities for OAB. EVIDENCE ACQUISITION: PubMed, Medline, and Cochrane databases were searched for all studies comparing outcomes of the available third-line treatment modalities for OAB. EVIDENCE SYNTHESIS: Several minimally invasive surgical procedures are available for patients with refractory OAB. These therapies include intravesical botulinum toxin type A, posterior tibial nerve stimulation, and sacral neuromodulation. CONCLUSIONS: None of the mentioned therapeutic modalities shows strong superiority over another. If the results of one therapy are not satisfactory, switching to another third-line treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns. All these factors should be taken into consideration before initiation of treatment. PATIENT SUMMARY: In the management of drug-resistant overactive bladder syndrome, the different minimally invasive treatments that are available are equal. If the results of one therapy are not satisfactory, switching to another treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns.

Efficacy and Safety of Sacral and Percutaneous Tibial Neuromodulation in Non-neurogenic Lower Urinary Tract Dysfunction and Chronic Pelvic Pain: A Systematic Review of the Literature.

CONTEXT: Neuromodulation is considered in patients with non-neurogenic lower urinary tract dysfunction (LUTD) not responsive to conservative treatment. OBJECTIVE: To systematically review the available studies on efficacy and safety of sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) in non-neurogenic LUTDs not responsive to conservative treatments. EVIDENCE ACQUISITION: A literature research was conducted in PubMed/Medline and Scopus, restricted to articles in English, published between January 1998 and June 2017, with at least 20 patients and 6 mo of follow-up. EVIDENCE SYNTHESIS: Twenty-one reports were identified. Concerning SNM, the improvement of ≥50% in leakage episodes ranged widely between 29% and 76%. Overall dry rate ranged between 43% and 56%. Overall success/improvement rate in PTNS varied between 54% and 59%. Symptom improvement or efficacy in interstitial cystitis/bladder pain syndrome patients appeared to be lower compared with other indications in both techniques. Safety data showed fewer side effects in patients submitted to PTNS. CONCLUSIONS: Neuromodulation gives good results and is a safe therapy for patients with overactive bladder or chronic nonobstructive urinary retention with long-lasting efficacy. Moreover, PTNS has been shown to have good success rates and fewer side effects compared with SNM. These data have to be confirmed with long-term follow-up. PATIENT SUMMARY: Sacral neuromodulation can improve low urinary tract symptoms in selected patients; it appears to be a safe therapy for nonresponders to standard medical therapies. Percutaneous tibial nerve stimulation (PTNS) is a less invasive technique that gives good results in short time with fewer side effects. However, we must consider that PTNS has not been tested in the long term and results are lower if compared with SNM.

Using imaging biomarkers to improve the planning of radical prostatectomies.

OBJECTIVES: This exploratory pilot study aimed to evaluate whether adding imaging biomarkers to conventional staging improves complete excision rates after undergoing radical prostatectomy (RP) in the United Kingdom for patients who have not undergone population prostate specific antigen screening. We primarily considered estimates of lesion volume and location based on computer-aided analysis of ultrasound (US) raw radiofrequency (RF) data acquired during trans-rectal ultrasound. The imaging analysis device used had been shown to accurately detect tumor loci within the prostate in previous studies. METHODS AND MATERIALS: US raw RF data were collected from motorized trans-rectal ultrasound of 68 consecutive men with operable prostate cancer. In this cohort (group 1), locations and volume measurements of lesions suspected of harboring cancer on US raw RF data analysis by prostate HistoScanning, were added to conventional presurgical staging.The unexposed control group comprised 100 men who underwent conventional presurgical staging only (group 2): 50 were operated before and 50 operated after group 1 recruitment. Changes to pre-operative surgical planning and positive lateral margins of RP prostate pathological specimens were the primary outcomes. Data were collected using a Microsoft Excel database and analyzed using Stata. RESULTS: Baseline demographics were comparable. In group 1, consideration of the additional imaging biomarkers led to changes in 27 (19.9%) operative surgical plans. Absolute rate reduction of a positive surgical margin (PSM) attributable to the imaging-biomarkers was 13.3% (P = 0.029). For stage pT3, PSM rate was reduced from 45.8% (n = 44) to 21.2% (n = 11) (P = 0.0028). CONCLUSIONS: Obtaining quantitative measurements of preoperative imaging biomarkers appears to improve PSM rates of patients undergoing RP. The greatest PSM rate reduction was observed for pT3 tumors.

Long-term efficacy of polydimethylsiloxane (Macroplastique) injection for Mitrofanoff leakage after continent urinary diversion surgery.

OBJECTIVE: To assess the long-term efficacy of polydimethylsiloxane (Macroplastique) injection (MPI) in the treatment of Mitrofanoff leakage secondary to valve incompetence. PATIENTS AND METHODS: Between 1995 and 2012, the records of 24 consecutive patients who underwent MPI for Mitrofanoff urinary leakage after continent cutaneous urinary diversion (CCUD) surgery were examined. All patients had a valve deemed of sufficient length (>2 cm) to attempt Macroplastique coaptation. Treatment outcomes were divided into three categories based on physician assessment: success (dry), partial success (>50% reduction in incontinence pads) and failure. Success rates were assessed according to the type of reservoir and conduit channel. RESULTS: The mean (range) follow-up was 30 (6-96) months. One patient had initial difficulty catheterising, and subsequently required major revision surgery. In all, 12 patients (50%) failed the treatment and subsequently underwent operative revision to the channel. Three patients (12.5%) achieved complete success; one patient had an appendix channel through native bladder and the remaining two had Monti channels through colon. Nine patients (37.5%) had partial success; success rates were higher with appendix channels (four of six) and colonic reservoirs (six of seven) when compared with Monti channels (eight of 18, 44%) and ileal reservoirs (zero of two). Five of the nine patients with partial success eventually required further surgical revision for deteriorating continence at a mean (range) of 41 (14-96) months, whilst the other four have maintained sufficient continence with MPI alone. CONCLUSION: Macroplastique bulking cured only 12.5% patients, but leakage was substantially improved in a further 37.5% allowing major surgery to be avoided or postponed in one half of the cohort. Appendix Mitrofanoffs do better than the Monti Mitrofanoff, with channels through colonic segments generally doing better than those through ileal bladders. MPI should be considered as a less invasive alternative to avoid or delay major reconstructive surgery.

Emerging treatments for overactive bladder: clinical potential of botulinum toxins.

Overactive bladder (OAB) is a symptom syndrome including urgency, frequency, and nocturia - with or without incontinence. It is a common manifestation of detrusor overactivity (DO). DO is a urodynamic observation of spontaneous or provoked contractions of the detrusor muscle is seen during the filling phase of the micturition cycle. OAB is, therefore, both a motor and sensory disorder. Botulinum toxin is a purified form of the neurotoxin from Clostridium botulinum and has been used in medicine for many years. Over the last 10 years, it has been used for the treatment of DO and OAB when standard treatments, such as bladder training and oral anticholinergic medication, have failed to provide symptom relief. Botulinum toxin acts by irreversibly preventing neurotransmitter release from the neurons in the motor end plate and also at sensory synapses, although the clinical effect is not permanent due to the growth of new connections within treated tissues. It is known that botulinum toxin modulates vanillioid, purinergic, capsaicin, and muscarinic receptor expression within the lamina propria, returning them to levels seen in normal bladders. Clinically, the effect of botulinum toxin on symptoms of OAB and DO is profound, with large effects upon the symptom of urgency, and also large effects on frequency, nocturia, leakage episodes, and continence rates. These effects have been seen consistently within eight randomized trials and numerous case series. Botulinum toxin appears safe, with the only common side effect being that of voiding difficulty, occurring in up to 10% of treated patients. Dosing regimens are variable, depending on which preparation is used, but it is clear that dose recommendations have fallen over the last 5 years. There is limited evidence about the efficacy of repeat treatments. Botulinum toxin is an effective and safe second-line treatment for patients with OAB and DO.

Male incontinence: onabotulinum toxin A and sacral nerve stimulation.

PURPOSE OF REVIEW: Overactive bladder affects 10-12% of men, of which 13% are refractory to medical therapy and seek second-line treatment. This places a substantial clinical and economic burden on the National Health Service United Kingdom. RECENT FINDINGS: This review identifies current evidence for the use of onabotulinum toxin A and sacral nerve neuromodulation for the treatment of overactive bladder in patients who do not respond to optimal medical treatment. Posterior tibial nerve stimulation is not covered here. Clinical and financial implications of the treatments are reviewed. SUMMARY: The focus will remain on recently published evidence, which may be useful to clinicians managing refractory patients.

Tumour-to-tumour metastases: prostate carcinoma metastasising to a renal oncocytoma.

This is a case report of prostate carcinoma metastasising to a renal oncocytoma. The report demonstrates the unusual presentation of metastases from a common cancer to a common benign tumour, and reviews the rare phenomenon of tumour-to-tumour metastases.