A narrative review on the performance and outcomes of penile and scrotal surgery in the ambulatory setting.

PURPOSE OF REVIEW: Following the COVID-19 pandemic, surgical wait times have surged, creating a backlog in elective urological procedures. This review aims to address the need to explore ambulatory care for penile and scrotal surgeries, which can offer benefits by shifting these procedures away from traditional inpatient settings. RECENT FINDINGS: Recent studies confirm the safety and efficacy of performing penile and scrotal procedures in an ambulatory setting using local anesthesia (LA) or loco-sedative techniques. Of 616 reviewed cases, over 90% of patients expressed high satisfaction with LA and reported minimal postoperative complications. Pain management advancements, particularly the use of liposomal bupivacaine, reduced the need for opioids postoperatively. Importantly, no intraoperative complications or hospital admissions were reported, and adverse events were managed conservatively. The data highlighted in this review supports a move towards outpatient surgeries as a safe alternative to inpatient care for select cases. SUMMARY: This review highlights the strong potential for ambulatory urological surgeries to alleviate surgical backlogs significantly, while reducing strain on hospital resources, and maintaining high levels of patient satisfaction. As evidence continues to grow on the safety, feasibility, and effectiveness of LA in office-based procedures, expanding ambulatory urological will be quintessential in modernizing patient care and reducing healthcare burdens.

Abdominal Lymphatic Malformations: A Novel Approach in Management.

AIM OF THE STUDY: Abdominal lymphatic malformations (LM) are a challenging clinical entity. Complete excision can be impossible due to the infiltrative nature of some lesions and high rate of complications. Sclerotherapy may require multiple episodes of general anaesthesia and an inability to be definitive in terms of diagnosis and treatment. Subsequently we have adopted a newer algorithm of treatment involving a joint procedure with interventional radiology to enable an intra-operative treatment plan based on the findings. We present our early results. METHOD: A retrospective observational study in a single tertiary paediatric centre from January 2019 to December 2023. The details of each patient were recorded along with their treatment pathway and outcome. RESULTS: 12 children underwent treatment for abdominal LM. Under GA and laparoscopic vision, pigtail catheters were inserted into the lesion to effect maximal drainage and assessment of surgical anatomy. If resection was feasible this was undertaken through a laparotomy and if not, the drains were retained and sclerotherapy was started. Three underwent drainage with sclerotherapy without resection and 9 underwent drainage with resection. Of the 3 who underwent sclerotherapy 2 have had further treatment and remain under review at a mean follow up of 7.6 months. Of the other 9 there were no signs of recurrence of the LM at a mean follow up of 29 (range 6-56) months. CONCLUSION: We have found a combined procedure involving IR-guided drainage under laparoscopic vision enabling curative surgical resection to be undertaken, where feasible, with currently no significant morbidity. For those in whom this is not possible then direct intralesional sclerotherapy is the next most useful treatment modality for longer term control of symptoms. LEVEL OF EVIDENCE: II.

Impact of pre-treatment counselling on decisional regret of prostate cancer survivors: Cross-sectional analysis of patient-reported experience following diagnosis or treatment.

INTRODUCTION: Prostate cancer (PCa) impacts patient lives beyond oncologic concerns alone. PCa survivorship entails all impacts of PCa, from time of diagnosis to end of life. This may include decision regret (DR). We aimed to determine survivor experiences from a functional perspective throughout survivorship. METHODS: Our cross-sectional survey was circulated to all members of the Manitoba Prostate Cancer Support Group. Questions explored patient understanding of functional impacts concerning treatment. Survey items included binary and Likert scale questions, and an open-answered question asking how care may be improved. Responses were used to identify predictors of DR. RESULTS: A total of 514 patients received our survey with a response rate of 23.7% (n=122). Most survivors were offered radical prostatectomy (RP) or radiation therapy, at 73.0% and 63.9%, respectively; 14.9% reported lacking understanding of treatment impact on erections. Similarly, 11.5% reported lacking understanding of treatment on urinary continence. Predictors of DR included treatment with RP and low pre-treatment understanding of potential erectile dysfunction (ED) and urinary incontinence. CONCLUSIONS: PCa survivors are at high risk of DR, particularly those who undergo treatment with RP and those who identify as having low pre-treatment understanding of potential ED and urinary incontinence. Virtual care did not impact DR. Results highlight the importance of thorough counselling on functional aspects of PCa management prior to treatment.

Efficacy of Rezum water vapor therapy for the treatment of catheter-dependent urinary retention: A single-center, Canadian experience.

INTRODUCTION: Urinary retention secondary to benign prostatic hyperplasia (BPH) requiring catheterization is a prevalent and morbid condition. The objective of this study was to evaluate the real-world efficacy and safety of Rezum as the primary treatment of catheter-dependent urinary retention. METHODS: A single-center, retrospective study analyzed patients with catheter-dependent urinary retention secondary to BPH who were treated with Rezum between April 2022 and April 2024. Standardized postoperative followup was required for inclusion. Patient demographics, medication use, volume drained at time of urinary retention, catheter-free status, complications, and postoperative International Prostate Symptom Score (IPSS) was collected. RESULTS: A total of 53 patients were included. Mean age was 73.4 years (standard deviation 9.4), and the mean Charlson comorbidity index score was 3.7. The baseline mean prostate volume was 81.7 (range 33-179) mL. Patients were catheter-dependent for an average of 225 (range 30- 1821) days prior to surgical intervention. Average followup time was 10.2 months. Of the 53 patients treated, 42 (79%) patients were able to become catheter-free after treatment. Twenty-six (49%) patients failed their initial trial of void at 14 days postoperatively; 11% (n=6) of patients experienced hematuria with one admitted to hospital due to hematuria/clot retention. There were no Clavien Dindo ≥3 complications. Only retention volume ≥1 L was a significant independent predictor of treatment failure on univariate and multivariate logistic regression analysis. CONCLUSIONS: Rezum effectively treated catheter-dependent urinary retention. Given the simplicity of treatment, accessibility, and minimal anesthetic requirements, providers should consider Rezum to minimize indwelling catheter-related morbidity for catheter-dependant patients.

Utilizing Local Anesthesia Only for Penile and Scrotal Urologic Surgery: A Prospective Study on Patient Tolerability and Surgical Outcomes for a Sedation-free Option.

OBJECTIVE: To prospectively assess surgical outcomes, complications, and patient-reported tolerability of invasive scrotal surgeries under local anesthesia (LA) alone, without sedation, compared to tolerability of penile procedures commonly performed in this manner. METHODS: Adult patients undergoing penile and scrotal surgeries under LA only were enrolled from August 2022 to June 2023 (NCT05617261). Demographics, surgeon-perceived and patient-reported pain, and surgical variables were collected. Tolerability to the procedures and future anesthetic choice for a repeat procedure was assessed on follow-up. Complication data were collected, including recurrence, infection, excessive pain, and emergency room and family physician visits. RESULTS: Hundred and seven patients were enrolled with a mean age ± SD of 42.2 ± 16.4 years. There was a 100% procedural success rate and no cases of perioperative complications or escalation of anesthetic. Around 92.4% (n = 97) of patients indicated they would opt for LA only for a hypothetical repeat procedure. Of the minority opting for general anesthetic, most indicated discomfort or preferring an element of amnesia. No differences between intraoperative pain or tolerability scores of invasive scrotal procedures compared to penile procedures were observed. On univariate analysis, longer procedure duration (P = .003), cannabis use (P = .01), and higher intra-operative pain (P = .005) was associated with lower tolerability. CONCLUSION: LA alone in an office-based setting is promising for scrotal surgeries. It offers similarly high patient tolerability compared to procedures that are routinely performed under LA, with the preservation of outcomes. Adopting this method has the potential for substantial cost savings, reduced wait times, enhanced accessibility, and improved surgical efficiency.

Interventional solutions for post-surgical problems: a lymphatic leaks review.

The lymphatic circulation plays a crucial role in maintaining fluid balance and supporting immune responses by returning serum proteins and lipids to the systemic circulation. Lymphatic leaks, though rare, pose significant challenges post-radical neck surgery, oesophagectomy, and thoracic or retroperitoneal oncological resections, leading to heightened morbidity and mortality. Managing lymphatic leaks necessitates consideration of aetiology, severity, and volume of leakage. Traditionally, treatment involved conservative measures such as dietary restrictions, drainage, and medical management, with surgical intervention reserved for severe cases, albeit with variable outcomes and extended recovery periods. Lymphography, introduced in the 1950s, initially served as a diagnostic tool for lymphoedema, lymphoma, tumour staging, and monitoring chemotherapy response. However, its widespread adoption was impeded by alternative techniques like Computed Tomography, learning curves, and its associated complications. Contemporary lymphatic interventions have evolved, favouring nodal lymphangiography over pedal lymphangiography for its technical simplicity and reduced complexity. Effective management of chylous leaks mandates a multimodal approach encompassing clinical evaluation and imaging techniques. In cases where conservative management proves ineffective, embolization through conventional lymphangiography by bipedal dissection or intranodal injection emerges as a viable option. This review underscores the importance of a comprehensive approach to diagnosing and treating lymphatic leaks, highlighting advancements in imaging and therapeutic interventions that enhance patient outcomes.

The safety and efficacy of ambulatory urologic surgery: A paradigm shift towards optimizing resource utilization in outpatient settings.

INTRODUCTION: Amidst substantial surgical waitlists, novel methods are needed to improve the delivery of surgical care in Canada. One strategy involves shifting select surgeries from hospitals into community ambulatory centers, which expedite procedures and allow hospitals to prioritize critical and complex patients. We sought to evaluate surgical outcomes at a novel Canadian urologic clinic and surgical center. METHODS: A retrospective study was conducted at a novel accredited surgical facility and outpatient ambulatory clinic from August 2022 to August 2023. Procedures ranged from scrotal and transurethral surgeries to inflatable penile prosthesis insertion. Traditional outpatient procedures, including vasectomy and cystoscopy, were excluded. All patients were discharged the same day and seen 4-6 weeks post-procedure. Variables of interest included surgery type, anesthesia administered, additional clinic appointments, unplanned family physician appointments, visits to the emergency department (ED), and hospital admissions. RESULTS: In a 12-month period, 519 surgeries were performed. The mean patient age was 49.6±17.3 years, with most classified as American Society of Anesthesiologists (ASA) 1-2 (88.8%). Most (95.8%, n=497) patients did not require medical care outside the clinic before scheduled followup; 2.5% (n=13) visited the ED presenting for wound concerns, postoperative pain, query infection, or catheter-related concerns. Only 1.7% (n=9) required an unscheduled appointment with their family physician, with concerns being inadequate postoperative pain management (n=4) or suspected infection (n=4). No patient required hospital admission. CONCLUSIONS: Many urologic surgeries classically performed in hospital operating rooms can be safely performed in a non-hospital, outpatient surgical facility with preservation of good outcomes. This strategy can potentially improve the efficiency of urologic healthcare delivery in select patients.

An overview of the Canadian landscape on the use of restorative therapies for erectile dysfunction and Peyronie's disease.

INTRODUCTION: Restorative therapies (RT(s)), including low-intensity shockwave therapy (Li-SWT) and platelet-rich plasma (PRP), aim to restore natural erectile function. Many clinics offer these therapies for erectile dysfunction (ED) and Peyronie's disease (PD) with direct-to-consumer (DTC) marketing. This study sought to investigate the landscape of RTs within Canadian clinics. METHODS: Online searches were made to identify clinics offering Li-SWT and/or PRP as an RT for treating ED and PD in Canada. Public websites were analyzed, followed by calling clinics for data on cost, treatment protocols, clinic ownership, success rates, and adjunctive therapies. RESULTS: A total of 107 clinics were identified online, with a 68.2% call response rate (n=73). Of the respondents, 56 and 40 clinics provided Li-SWT and PRP therapies, respectively, with 23 clinics offering both. All clinics reported using RTs for ED, with 21 clinics offering Li-SWT and 22 clinics providing PRP for PD. Forty-three clinics provided costs and protocols for Li-SWT, while 33 clinics did so for PRP. The average cost + standard deviation (CAD) of six sessions of Li-SWT was $2167.24+936.11 and one shot of PRP was $1478.68+591.98. Most (60.3%, n=44) clinics reported physician ownership, with a majority (n=28) being family medicine trained. Seven clinics did not provide data and 22 were non-MD-owned. Ten clinics provided success rates, with an average of 87.3%. CONCLUSIONS: Despite limited data supporting their routine clinical use, many clinics across Canada offer RTs for ED and PD with varying treatment protocols and increased costs. Further research is required to evaluate the efficacy of RT for ED and PD.

The Impact of a 4-Domain Wellness-Initiative Curriculum on Internal Medicine Resident Physicians.

Background: There is a trend toward fostering well-being, or the state of being happy and healthy, within the medical community. Historically, resident physicians have faced high rates of distress during training. A structured well-being curriculum in residency programs may shift residents' mindsets from survival and resilience to one centered on purpose, engagement, and joy. Methods: An original well-being curriculum was administered to residents in person at a single institution every 5 weeks for approximately 10 well-being workshops, totaling around 20 hours of curriculum exposure during every academic year. The well-being curriculum was divided into 4 domains: cognitive distortions and problematic mindsets, mindfulness and meditation, creative outlets, and self-compassion.Residents exposed to at least 1 year of the well-being curriculum were asked to answer an anonymous survey. Four questions were asked for each of the 4 domains. The first and second questions asked how familiar they were with the topic before and after the workshops on a scale of 1-5 of familiarity. The third and fourth questions asked how much the knowledge acquired influenced their professional and personal life on a scale of 1-5 of influence. Results: Before curriculum exposure, the average for moderate or higher levels of knowledge across all domains was 22.7%, which improved to 77.3% after curriculum completion. Overall, 58.6% of participants felt the knowledge of the domains was moderately or extremely influential in their professional lives and 83.6% in their personal lives. There were no significant differences between post-graduate year 2 and post-graduate year 3 residents for any domains examined before and after the wellness workshops. Conclusion: A 4-domain well-being curriculum practiced in a group setting positively impacted participating residents in their personal and professional lives. Further studies need to be performed on a larger scale to assess if the curriculum fits the needs of the broader medical community.

Efficacy of EMLA for Office-based Andrology Procedures Under Local Anesthesia: A Randomized Control Trial.

OBJECTIVE: To evaluate the effectiveness of Eutectic Mixture of Local Anesthetic (EMLA), a topical anesthetic cream, in office-based invasive andrological procedures such as hydrocelectomy, spermatocelectomy, and others, aimed at minimizing pain perception and enhancing the overall patient experience. METHODS: A double-blinded randomized controlled trial was conducted for patients undergoing scrotal andrology surgeries under LA. Power calculation was performed with an estimated sample size of 72. Participants were randomly assigned in a 1:1 ratio to topical EMLA + LA versus LA alone. In the post-operative recovery area, patient will be asked to complete a VAS questionnaire rating pain with LA administration and pain with procedure. Analysis comparing VAS pain scores of both groups was performed using the independent sample t-test method. RESULTS: Seventy-two patients were included in our analysis, with 36 in the control and 36 in the intervention arm. For patient pain with administration of LA, the control arm reported an average VAS pain score of 4.31, compared to 3.72 in the intervention arm (P = .319). For patient pain with procedure, patients in the control arm reported a median VAS pain score of 3.47 compared to 3.03 (P = .432) in the intervention arm. Overall, 86% (62/72) of patients reported that they would either be "very likely" (4/5) or "highly likely" (5/5) to undergo future procedures under local anesthetic. CONCLUSION: While performing scrotal surgeries under LA appears to be well tolerated and a feasible option, the application of EMLA cream does not appear to significantly alter patient-reported outcomes.

The landscape of male contraception A narrative review.

Reproductive medicine has made significant advancements over the last 70 years, much of it in the way of female contraception. Reliable male contraception continues to be restricted to condoms and vasectomy. The purpose of this narrative review is to provide an overview of the contemporary usage of male contraceptive methods, including ethical and political standpoints, as well as to summarize current and future studies being done on male hormonal and non-hormonal contraceptive options.

Outcomes following inguinal and subinguinal urologic procedures under deep intravenous sedation.

INTRODUCTION: We aimed to investigate the surgical outcomes following inguinal and subinguinal urologic procedures under deep intravenous sedation (DIVS) with multimodal local anesthesia (LA). METHODS: We conducted a retrospective cohort study from September 2022 to December 2023 including adult patients deemed eligible for day surgery (American Society of Anesthesiologist score 1-3) undergoing radical orchiectomy (RO), microscopic varicocelectomy (MV), or microscopic denervation of the spermatic cord (MDSC). All procedures were performed at a single urologic ambulatory surgical center and outpatient clinic, and by a single surgeon (PP). Procedures were performed through a subinguinal or inguinal approach with DIVS and adjunctive multimodal LA. We evaluated intraoperative complications and relevant surgical outcomes and parameters. RESULTS: A total of 103 patients were included in the analysis with a mean age ± standard deviation of 37.3±9.6. This included 25 patients who underwent RO, 54 patients who underwent MV, and 24 patients who underwent MDSC. All procedures were completed successfully without intraoperative complications. Oncologic outcomes were preserved, fertility outcomes improved, and pain scores reduced similarly to the expected rates in the literature. CONCLUSIONS: Our preliminary results demonstrate the safety, effectiveness, and feasibility of performing inguinal and subinguinal urologic procedures under DIVS with LA. These findings suggest that this technique preserves high-quality care while avoiding the unnecessary risks of general or spinal anesthesia, representing an opportunity to transfer these cases outside of hospitals' operating rooms into outpatient ambulatory centers.

Interventional oncology in children: Where are we now?

Paediatric Interventional Oncology (IO) lags behind adult IO due to a scarcity of specific outcome data. The suboptimal way to evolve this field is relying heavily on adult experiences. The distinct tumour types prevalent in children, such as extracranial germ cell tumours, sarcomas, and neuroblastoma, differ strongly from those found in adults, presenting a completely different biological behaviour. Compounding this challenge, paediatric interventional radiology often employs adapted or off-label techniques, potentially compromising optimal outcomes. This review outlines the present indications for interventional radiology in paediatric cancer, from biopsy to supportive care, including complication management. It emphasises the role of locoregional approaches, and explores the status of common paediatric oncological diseases, highlighting areas where IO has made progress identifying potential opportunities for future advancements in this evolving field.

Prospective Pilot Study: Tolerability of Outpatient Penile Plication Under Nursing-Administered Conscious Sedation vs Anesthesiologist-Administered Deep Sedation.

INTRODUCTION: Penile plication is commonly performed for Peyronie's disease under general or spinal anesthesia. Conscious sedation (CS) offers decreased anesthetic risks, cost-effectiveness, and the ability to perform the procedure in outpatient settings with shorter wait times. We sought to compare tolerability of penile plication under deep intravenous sedation (DIS) administered by anesthesiologists and nursing-administered CS (NACS). METHODS: Tolerability for penile plication was prospectively evaluated, excluding revision surgeries and those with hourglass or hinge deformities. DIS included midazolam and ketamine with infusion of propofol and remifentanil. NACS consisted of midazolam and fentanyl. Baseline characteristics, procedural information, and patient- and surgeon-reported pain assessments were collected. Patients were administered a standardized tolerability questionnaire on follow-up. RESULTS: Forty patients were enrolled (23 DIS; 17 NACS) with similar baseline characteristics. Median curvature of the DIS cohort was 55° (interquartile range = 43.75-76.25) and 45° (interquartile range = 45-60) in NACS. There was a 100% success rate with no procedure abortion or conversion to general anesthetic. On follow-up, all patients had functional curvature (<20°), and 100% of patients in the DIS and NACS cohorts reported that they would recommend CS to others. Over 93% of patients in both cohorts would choose CS over general anesthetic in the future, with no differences in perioperative and postoperative pain between groups. CONCLUSIONS: Penile plication with CS, whether administered by an anesthesiologist or nursing, is well tolerated with no differences in pain or complications. This indicates that outpatient penile plication with trained nursing staff administering CS can safely reduce costs, risks, and wait times.

A Systematic Review of Loco-Sedative Anesthesia for Urologic Surgery.

OBJECTIVE: To perform a systematic review of the characteristics and outcomes of conscious sedation and local anesthesia for various urologic procedures. Urologic care has much to gain from the routine integration of ambulatory surgery via loco-sedative anesthetic techniques for both surgeon and patient. METHODS: A comprehensive systematic literature search was conducted on PubMed, and Scopus databases following PRISMA criteria from June to August 2021. Articles were included if they were English, prospective, randomized, or nonrandomized controlled trials that used local anesthetic or conscious sedation for urologic interventions in adult patients. Additionally, included studies provided primary data on the use loco-sedative anesthesia and the efficacy and complications. All studies included were further reviewed to assess the biases and conflicts of interests. RESULTS: Thirty-two studies with 6897 patients were included in the review. Mean patient age was 46.4years. The most common anesthetic and analgesic relief was the use of local anesthetic with 1% lidocaine. The majority used lidocaine as an injection, whereas the second most common route of administration was a topical cream. However, there was significant heterogeneity in the type of local or conscious sedation method and whether a combination was used. 44.4% of the studies used the visual analog scale as their primary endpoint. All the studies reported an 83%-100% successful procedure rate without note of significant sedation-related complications. CONCLUSION: Given the high efficacy rates, loco-sedative anesthesia is a promising technique for urologic interventions and should be further investigated to determine whether it may become be the standard of care.

Risk of major adverse cardiovascular events in rural vs urban settings among patients with erectile dysfunction: a propensity-weighted retrospective cohort study of 430 621 men.

BACKGROUND: The relationship between erectile dysfunction (ED) and cardiovascular (CV) events has been postulated, with ED being characterized as a potential harbinger of CV disease. Location of residence is another important consideration, as the impact of rural residence has been associated with worse health outcomes. AIM: To investigate whether men from rural settings with ED are associated with a higher risk of major adverse CV events (MACEs). METHODS: A propensity-weighted retrospective cohort study was conducted with provincial health administrative databases. ED was defined as having at least 2 ED prescriptions filled within 1 year. MACE was defined as the first hospitalization for an episode of acute myocardial infarction, heart failure, or stroke that resulted in a hospital visit >24 hours. We classified study groups into ED urban, ED rural, no ED urban, and no ED rural. A multiple logistic regression model was used to determine the propensity score. Stabilized inverse propensity treatment weighting was then applied to the propensity score. OUTCOMES: A Cox proportional hazard model was used to examine our primary outcome of time to a MACE. RESULTS: The median time to a MACE was 2731, 2635, 2441, and 2508 days for ED urban (n = 32 341), ED rural (n = 18 025), no ED rural (n = 146 358), and no ED urban (n = 233 897), respectively. The cohort with ED had a higher proportion of a MACE at 8.94% (n = 4503), as opposed to 4.58% (n = 17 416) for the group without ED. As compared with no ED urban, no ED rural was associated with higher risks of a MACE in stabilized time-varying comodels based on inverse probability treatment weighting (hazard ratio, 1.06-1.08). ED rural was associated with significantly higher risks of a MACE vs no ED rural, with the strength of the effect estimates increasing over time (hazard ratio, 1.10-1.74). CLINICAL IMPLICATIONS: Findings highlight the need for physicians treating patients with ED to address CV risk factors for primary and secondary prevention of CV diseases. STRENGTHS AND LIMITATIONS: This is the most extensive retrospective study demonstrating that ED is an independent risk factor for MACE. Due to limitations in data, we were unable to assess certain comorbidities, including obesity and smoking. CONCLUSIONS: Our study confirms that ED is an independent risk factor for MACE. Rural men had a higher risk of MACE, with an even higher risk among those who reside rurally and are diagnosed with ED.

An analysis of benign prostatic hyperplasia surgical treatment reimbursement trends across Canada Examining provincial changes over the recent decade with comparison to cost of living changes.

INTRODUCTION: A variety of procedures for the endoscopic surgical treatment of symptomatic benign prostatic hyperplasia (BPH) refractory to medical therapy have existed for decades. The present study examined trends in surgeon compensation for these treatments within Canada. METHODS: The physician fee schedule for BPH surgery across 10 Canadian provinces for the years 2010 and 2023 were obtained. A descriptive study examined first the provincial reimbursement for transurethral resection of prostate (TURP) and laser ablative/enucleation surgery; second, the difference in TURP reimbursement between 2010 and 2023; and third, the annual change in TURP reimbursement juxtaposed with the annual change in the provincial Consumer Price Index (CPI) and annual salary for the working population aged 35-44. RESULTS: Seven of 10 Canadian provinces reimburse laser BPH surgery equally to TURP. The average provincial TURP reimbursement is $545, ranging from $451 in Ontario to $688 in Saskatchewan. Since 2010, TURP reimbursement has varied by province from a 0% net change in Ontario to an increase of 21% in Nova Scotia. Reimbursement for TURP has increased at a slower pace than the local CPI, and for half of the provinces at a slower pace than the annual salary for people aged 35-44. CONCLUSIONS: The compensation model for endoscopic BPH surgery does not have a unified structure in Canada that is consistent across provinces, nor does it keep up with inflation, possibly impacting future recruitment, increasing geographic disparities, and most importantly, limiting the adoption of new BPH therapies.