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 examines 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 examining 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.

Control4Life: A randomized controlled trial protocol examining the feasibility and efficacy of a combined pelvic health rehabilitation and exercise fitness program for individuals undergoing prostatectomy.

BACKGROUND: Urinary incontinence (UI), erectile dysfunction and cardiometabolic conditions are common after prostatectomy for prostate cancer (PCa). Although physical activity could improve overall survival and quality of survivorship, fear of UI can restrict participation in exercise. Individuals with PCa could benefit from therapeutic exercise programming to support continence recovery and cardiometabolic health. AIM: The main objective of this study is to determine the feasibility and the effects of a combined pelvic health rehabilitation and exercise fitness program on UI after prostatectomy. The combined exercise program will be delivered both in-person and virtually. METHODS: This study follows a modified Zelen, two-arm parallel randomized controlled trial design. A total of 106 individuals with PCa will be recruited before prostatectomy surgery. Participants will be randomized between two groups: one receiving usual care and one receiving a combined exercise fitness and intensive pelvic floor muscle training program. Exercise programming will begin 6-8 weeks after prostatectomy and will last 12 weeks. Outcomes include: the 24-h pad test (primary outcome for UI); physical fitness, metabolic indicators, and patient-reported outcomes on erectile function, self-efficacy, severity of cancer symptoms and quality of life. Important timepoints for assessments include before surgery (T0), after surgery (T1), after intervention (T3) and at one-year after surgery (T4). CONCLUSION: This study will inform the feasibility of offering comprehensive exercise programming that has the potential to positively impact urinary continence, erectile function and cardiometabolic health of individuals undergoing prostatectomy for prostate cancer. CLINICALTRIALS REGISTRATION NUMBER: NCT06072911.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. METHODS: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. RESULTS: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). CONCLUSIONS: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Recurrence and upstaging rates of T1 high-grade urothelial carcinoma of the bladder on repeat resection in a Canadian, resource-limited, healthcare system.

INTRODUCTION: Non-muscle-invasive bladder cancer is the most expensive malignancy to treat. Current Canadian guidelines recommend repeat transurethral resection of bladder tumour (TURBT) within six weeks after initial resection of T1 high-grade (T1HG) urothelial carcinoma, prior to initiation of intravesical bacillus Calmette-Guerin treatment. This is a burden on operating room usage and adds further cost and risk of complications. Internationally, major cancer centres report significant rates of recurrence and upstaging on repeat resection, however, minimal Canadian data is available. We aimed to determine the rate of recurrence and upstaging in a resource-limited, Canadian healthcare system. METHODS: A retrospective review of patients receiving TURBT between November 2009 and November 2014 was performed. Patients were included if they had all three of the following: a pathological diagnosis of T1HG, adequate muscularis propria present in the specimen, and a repeat resection. RESULTS: We reviewed 3166 patients who underwent TURBT and found 173 to meet our inclusion criteria. The overall recurrence and upstaging rates were 57.2% and 9.2%, respectively. Tumour recurrence and upstaging occurred more often in patients who had repeat resection after 12-24 weeks compared to those patients whose repeat resection occurred within 12 weeks. CONCLUSIONS: Although recurrence rates are similar, we have found upstaging rates to be three- to four-fold lower than those previously reported. Despite this, one in 10 patients will be upstaged, justifying use of this resource within our healthcare system. Finally, timely repeat resection, within 12 weeks appears to be associated with preventing disease progression.

Evaluating the role for renal biopsy in T1 and T2 renal masses: A single-centre study.

INTRODUCTION: Once used primarily in the identification of renal metastasis and lymphomas, various urological bodies are now adopting an expanded role for the renal biopsy. We sought to evaluate the role of the renal biopsy in a Canadian context, focusing on associated adverse events, radiographic burden, and diagnostic accuracy. METHODS: This retrospective review incorporated all patients undergoing ultrasound (US)/computed tomography (CT)-guided biopsies for T1 and T2 renal masses. There were no age or lesion size limitations. The primary outcome of interest was the correlation between initial biopsy and final surgical pathology. A binomial logistic regression analysis was conducted to determine any confounding factors. Secondary outcomes included the accuracy of tumour cell typing, grading, the safety profile, and radiographic burden associated with these patients. RESULTS: A total of 148 patients satisfied inclusion criteria for this study. Mean age and lesions size at detection were 60.9 years (±12.4) and 3.6 cm (±2.0), respectively. Most renal masses were identified with US (52.7%) or CT (44.6%). Three patients (2.0%) experienced adverse events of note. Eighty-six patients (58.1%) proceeded to radical/partial nephrectomy. Our biopsies held a diagnostic accuracy of 90.7% (sensitivity 96.2%, specificity 87.5%, positive predictive value 98.7%, negative predictive value 70.0%, kappa 0.752, p<0.0005). Binomial logistic regression revealed that age, lesion size, number of radiographic tests, time to biopsy, and modality of biopsy (US/CT) had no influence on the diagnostic accuracy of biopsies. CONCLUSIONS: Renal biopsies are safe, feasible, and diagnostic. Their role should be expanded in the routine evaluation of T1 and T2 renal masses.

Open removal as a first-line treatment of magnetic intravesical foreign bodies.

Intravesical foreign bodies are an uncommon, but significant, cause of urologic consultation. We present 3 patients who all inserted magnetic beads per urethra into the urinary bladder, which subsequently became retained. Endoscopic attempts were unsuccessfully tried in the first 2 cases, necessitating open cystotomy to remove the beads. The third went straight to open removal. Given the failure of minimally invasive techniques, we believe that open removal should be the first-line treatment for these types of foreign bodies.

Clear cell myomelanocytic tumour: minimally invasive treatment of a rare bladder tumour.

Clear cell myomelanocytic tumours are extremely rare neoplastic growths considered to be members of the family of perivascular epithelioid cell tumours (PEComas), which have in common the coexpression of melanocytic and smooth muscle immunohistochemical markers. These tumours are known to be ubiquitous with uncertain tumour biology and to have unpredictable clinical behaviour. They have been reported in the genitourinary tract, including the kidney and prostate. There are only 3 reported cases of clear cell myomelanocytic tumours originating in the urinary bladder. We report a case of a 24-year-old woman with chronic pelvic pain who underwent laparoscopic partial cystectomy and total excision of a bladder mass. Pathological examination revealed primary PEComa of the urinary bladder. Subsequent follow-up procedures, including cystoscopy and imaging, have not revealed any evidence of disease recurrence. The patient remains clinically free of disease 3 months after surgery.

Externalized urachal suture: novel approach to bowel and bladder retraction during transperitoneal laparoscopic radical prostatectomy.

INTRODUCTION: Although laparoscopic radical prostatectomy (LRP) has emerged as a legitimate minimally invasive surgical alternative to open radical retropubic prostatectomy, the technical difficulty of this advanced laparoscopic procedure remains an obstacle to its widespread use. We report a novel surgical technique for the purpose of bowel and bladder retraction during transperitoneal LRP that improves visualization and negates the need for additional working ports or steep Trendelenburg positioning. TECHNICAL CONSIDERATIONS: A 35-cm absorbable suture is secured intracorporeally to the urachus. The distal end of the suture is then pulled out through the left subcostal abdominal wall in the midaxillary line using a Carter-Thomason CloseSure device. Application of tension on the suture retracts the bladder superiorly and prevents bowel from entering the surgical field. This maneuver provides excellent exposure of the bladder neck and prostate and minimizes the need for additional fan retraction or steep Trendelenburg positioning. In 20 consecutive procedures, this step added an average of 2.2 minutes to the operative time, which averaged 169 minutes overall. CONCLUSIONS: Incorporation of an adjustable externalized urachal suture allows for excellent retraction of both bowel and bladder. This allows transperitoneal LRP to be performed using a four-port approach with minimal need for additional retraction or steep Trendelenburg positioning. In light of these benefits, the urachal suture has been incorporated as a routine step in transperitoneal LRP at our institution.

A review of prey choice in bembicine sand wasps (Hymenoptera: Sphecidae) / Revisão sobre a escolha de presa por vespas bembicineas (Hymenoptera: Sphecidae)

As presas de 132 espécies de vespas Bembicini (Hymenoptera) que foram estudadas são revisadas. Cerca de três quartos das espécies predam Diptera e acredita-se que a predação de moscas é um evento ancestral no grupo. Onze espécies predam, além de Diptera, ocasionalmente ou regularmente espécies de Lepidoptera, Hymenoptera, Neuroptera, Odonata e/ou Homoptera. Entretanto, outras 21 espécies pertencentes a cinco gêneros predam espécies das cinco ordens mencionadas, mas não predam Diptera. Especula-se que esse fato represente uma progressão evolucionária, quando populações de vespídeos foram expostas à escassez de dípteros no passado e foram obrigadas a ampliar o foco incluindo presas pertencentes a outros grupos de insetos voadores. Esse comportamento inicialmente aprendido foi revigorado geneticamente ao longo do tempo evolucionário para produzir a radiação atual no número de presas dentro do grupo.

The prey of 132 species of Bembicini (Hymenoptera) that have been studied is reviewed. About three quarters of the species prey on Diptera, and it is believed that fly predation is ancestral in the group. Eleven species make occasional or regular use of other insects as prey in addition to Diptera (Lepidoptera, Hymenoptera, Neuroptera, Odonata, and/or Homoptera), while 21 species of five genera prey on insects of these same five groups with no use of Diptera. It is hypothesized that this represents an evolutionary progression, whereby populations have experienced shortages of dipterous prey in the past and have broadened their sensory focusing to include other groups of flying insects. Behavior initially learned has, over time, been reinforced genetically to produce the currently observed radiation in prey choice within the group.