Objective Patients with overactive bladder (OAB) refractory to first‐ and second‐line therapy may pursue third‐line therapies, including intradetrusor onabotulinum toxin‐A (BTX), peripheral tibial nerve stimulation (PTNS), and sacral neuromodulation (SNM). The factors that influence patient preference for each treatment modality have not yet been explored. This study sought to investigate the specific parameters that patients consider in choosing a third‐line therapy for OAB. Methods Patients refractory to first‐ and second‐line therapies for OAB were identified in our outpatient clinic and asked to watch an educational video providing information on the risks and benefits of each third‐line treatment option. They were then given a questionnaire to rank their preference of therapy and select reasons for why they found each therapy favorable and unfavorable. Patients under age 18 years, non‐English speakers, those with a developmental disability, and those with a diagnosis of neurogenic bladder were excluded. Results Of the 98 patients included in the study, 40 participants (40.8%) chose intradetrusor BTX injections, 34 (34.7%) chose PTNS, and 16 (16.3%) chose SNM as their first choice. Seven patients (7.1%) chose none of the offered therapies, and one patient (1.0%) chose all three therapies with equal preference. BTX was found most attractive for its long efficacy (47%); its least attractive feature was the potential need for self‐catheterization due to urinary retention (54%). PTNS was found most attractive for being a nonsurgical option (32%) and having no reported significant complications (39%); its least attractive feature was need for frequent office visits (61%). SNM was found most attractive for its potential for long‐term relief without frequent office visits (53%); its least attractive feature was need for an implanted device (33%). Patients opting for SNM had higher scores on Urinary Distress Inventory‐6 and Incontinence Impact Questionnaire‐7 questionnaires when compared to patients opting for BTX injections or PTNS (p < 0.05). 47.4% of patients eventually pursued a third‐line therapy. Of those, there was a 67.6% concordance rate between the therapy patients ranked first and the therapy they eventually underwent. Conclusions Patients with more severe OAB symptoms opt for more invasive and less time‐consuming therapy with the potential for long‐term relief, namely SNM. Despite thorough counseling, many patients do not progress to advanced OAB therapies. Understanding factors that influence patients' affinity toward a specific type of treatment can aid with individualized counseling on third‐line OAB therapies.

Introduction:As part of its mission to provide the highest standards of clinical care, the AUA publishes guidelines on numerous urological topics. We sought to evaluate the caliber of evidence used establish the currently available AUA guidelines.Methods:All available AUA guideline statements in 2021 were reviewed for their level of evidence and recommendation strength. Statistical analysis was performed to identify differences between oncological and nononcologic topics, and statements pertinent to diagnosis, treatment, and follow-up. A multivariate analysis was utilized to identify factors associated with strong recommendations.Results:A total of 939 statements across 29 guidelines were analyzed; 39 (4.2%) were backed by Grade A evidence, 188 (20%) Grade B, 297 (31.6%) Grade C, 185 (19.7%) Clinical Principle, and 230 (24.5%) Expert Opinion. There was a significant association of oncology guidelines (6% vs 3%, P = .021) with more grade A evidence and less Grade C Evidence (24% vs 35%, P = .002). Statements pertaining to diagnosis and evaluation were more likely backed by Clinical Principle (31% vs 14% vs 15%, P < .01), treatment statements backed by B (26% vs 13% vs 11%, P < .01) and C (35% vs 30% vs 17%, P < .01) grade evidence, and follow-up statements backed by Expert Opinion (53% vs 23% vs 24%, P < .01). On multivariate analysis, strong recommendations were more likely supported by high-grade evidence (OR = 12, P < .01).Conclusions:The majority of evidence for the AUA guidelines is not high grade. Additional high-quality urological studies are needed to improve evidence based urological care.

Introduction Using hemostatic agents to manage intraoperative bleeding or assist in surgical closures is well established practice. Currently, several hemostatic agents such as Arista™, Surgiflo®, and Surgicel® are available for surgeon use when placing inflatable penile prosthesis (IPP). However, the effect of these agents on postoperative infection remains to be seen. Thus, we conducted a study to compare postoperative infection and reoperation rates of Arista™ to other hemostatic agents. Objective Primary objective was to determine if use of Arista™, when compared to other hemostatic agents, was associated with decreased rates of infection and reoperation in patients from a diverse, multiethnic population undergoing a primary IPP implantation. Methods A single institution retrospective study of patients who underwent IPP implantation between December 2015 and February 2022 from a single surgeon was conducted. Patients were sorted into groups based on use of intraoperative hemostatic agents. Demographic data, intra- and peri-operative patient characteristics, reoperation, and post-operative infection information was extracted from electronic medical records. Results A total of 434 patients undergoing primary IPP (95.4% Coloplast and 4.6% AMS devices) met inclusion criteria; of which, 158 (36.4%) received Arista™ and 276 (63.6%) received other hemostats such as Surgiflo®, and Surgicel®. There was no significant difference between age, race, preferred language, BMI, or smoking status between the Arista™ and other hemostat groups. Cardiovascular disease (CVD) and diabetes were prevalent in 76.7% and 56.3% of our sample, respectively. A vast majority (84%) of CVD patients had concomitant diabetes. Median Operative time was significantly shorter in the other hemostat group compared to the Arista™ group (62 minutes vs. 75, P &lt;0.001). There was no significant difference in post-operative instances of urinary retention, emergency department visits, or readmission between the two hemostat groups. Multivariable model controlling for age and CVD (Table 1) revealed that Arista™ was associated with significantly decreased odds of postoperative infection and reoperation when compared to other hemostats (OR = 0.36; 95% CI (0.14 – 0.97), P=0.04). Conversely, active smoking were associated with significantly higher odds (OR = 3.92; 95% CI (1.39 – 11.04), P=0.01). Conclusions Our retrospective study indicates that use of Arista™, regardless of patient CVD status, may lead to decreased infections and subsequent reoperations. Prospective randomized control trials should be pursued to adequately assess the benefits of Arista™ compared to other hemostatic agents. Disclosure No

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ImportanceOnabotulinumtoxinA (BTX-A) injection is a third-line therapy for overactive bladder (OAB). Patients undergoing treatment have a 6.5% chance of requiring clean intermittent catheterization (CIC) due to postoperative urinary retention (POUR).ObjectiveThe aim of this study was to evaluate risk factors for retention after BTX-A injections for OAB to decrease treatment hesitancy and enhance shared decision-making.Study DesignThis is a retrospective review of patients who underwent BTX-A injection for OAB at an urban university hospital between November 2015 and January 2021. Patients with neurogenic OAB, incomplete follow-up, or concomitant vaginal surgery were excluded. The primary outcome was POUR requiring CIC or postvoid residual volume (PVR) >200 mL at follow-up visit. Secondary outcomes included number of BTX-A injections, interval to reinjection, and whether patients reported symptom improvement.ResultsOur sample (N = 185) was 84% female with high prevalence of obesity (50%) and diabetes (32%). Twenty-one (11.4%) met the criteria for POUR with 17 (9.2%) requiring CIC. The retention and nonretention groups were similar in age, sex, smoking history, body mass index (BMI), hemogloblin A1c, and birth history, but significantly differed in preoperative PVR. Logistic regression revealed that patients with preoperative PVR 100+ mL had nearly 4-fold higher odds of POUR compared with patients with PVR less than 50 mL (odds ratio, 3.77; 95% confidence interval, 1.08–16.19).ConclusionsOur findings reassure patients with high BMI, as well as their physicians, that retention after BTX-A injection is not associated with BMI. However, patients presenting with high baseline PVR (100 + mL) should be counseled regarding a potentially higher risk of retention after BTX-A injection.