Secondary Analysis of Interstitial Cystitis/Bladder Pain Syndrome Patients Enrolled in a Recurrent Urinary Tract Infection Prevention Study Provides a Novel Paradigm for Etio-Pathogenesis and Practical Management of This Infection Phenotype.

INTRODUCTION: A subset of interstitial cystitis/bladder pain syndrome (IC/BPS) patients experience recurrent urinary tract infection (rUTI) associated with symptom flares. Recurrent UTI subjects with associated IC/BPS were enrolled in the first North American early clinical experience trial evaluating a new sublingual UTI preventative vaccine, MV140. It has been shown that women with rUTI develop an imbalance in the T helper 1 and 2 (Th2 over-expression) in the bladder mucosa. Our hypothesis-generating secondary analysis will suggest that this infection subcategory of IC/BPS patients develop a similar imbalance of Th1-Th2 response type to bacteria present in their urinary microbiome, leading to a bladder hypersensitivity that responds to mucosal immune modulation. METHODS: Female participants with ≥3 documented UTI/year underwent a 3-month vaccination treatment period with a 9-month efficacy period after completion of vaccine treatment (total 12 months). There were no exclusion criteria for subjects in relation to baseline urinary symptoms and/or discomfort/pain. Primary outcome was no UTI following vaccination. Secondary outcomes included change in UTI incidence, overall patient-reported subjective global assessment (SGA responder defined as moderately or markedly improved on 7-point scale), and safety. RESULTS: Sixteen subjects with IC/BPS-related symptoms and rUTI (mean age 47; range 23-74 years; mean number of UTI episodes in previous year 6.1 +/- 4.2) were eligible to be included in the Health Canada-approved MV140 vaccine study for prevention of rUTI. All subjects completed the 3-month vaccination period. One subject was lost to follow-up after their 6-month visit. Six subjects were UTI-free, while all 16 subjects had a reduction in UTI episodes compared to the year pre-vaccination. The total post-vaccination reduction in UTI episodes compared to pre-vaccination was 80% (0.1 UTI/subject/month from 0.5 UTI/subject/month, respectively). At 12 months, 13 subjects (81%) were SGA responders (moderately or markedly improved), and the responders reported a reduction in IC/BPS symptoms, with 8 subjects reporting significant or almost complete resolution of their specific long-term bladder discomfort/pain and bothersome urinary frequency or urgency. Four subjects reported mild and self-limited adverse events during vaccination period, but none were related to MV140 vaccine. CONCLUSION: Sublingual MV140 vaccine in IC/BPS patients with rUTI not only achieved UTI-free or reduced UTI incidence status but also, after approximately 9 months post vaccination, resolution of patients' long-term treatment-refractory IC/BPS symptoms. This suggests some cases of IC/BPS may be etiologically based on Th2-driven hypersensitivity to bacteria within or entering the urinary microbiome that responds to a vaccine whose mechanism of action is to normalize or balance the bladder Th1/Th2 mucosal immune system.

MV140 sublingual vaccine reduces recurrent urinary tract infection in women Results from the first North American clinical experience study.

INTRODUCTION: This is the first North American clinical evidence for MV140, a novel bacterial sublingual vaccine, developed for prevention of recurrent urinary tract infection (UTI) in women. METHODS: Female subjects with ≥3 documented UTIs/year underwent three-month vaccination treatment, nine-month efficacy period, and optional three-month followup (total 15 months). Primary outcome was no clinically diagnosed UTI following vaccination (UTI-free rate). Secondary outcomes included absolute, mean, and median overall reduction in UTI compared to pre-vaccination, quality of life, global response assessment, patient satisfaction, microbiology, and safety. RESULTS: Sixty-seven subjects (mean age 56 years, range 18-80) were enrolled; 64 completed the vaccination period and at least one post-vaccination assessment. Prior to vaccination, subjects reported a mean 6.8 UTIs/year. The UTI-free rate for the nine-month efficacy period was 40.6%. Compared to the infection rate in the year prior to vaccination, the reduction was 75.3% for the nine-month efficacy period post-vaccination. At 12-month followup, 80.3% reported that they were moderately/markedly improved; 58.1% were mostly satisfied, pleased, or delighted, while mean quality of life score improved by 1.5 points. Fourteen of the adverse events in nine subjects were potentially related to the vaccine - all mild and resolved by three months. None of the 13 serious adverse events were related to vaccine. CONCLUSIONS: This first-in-North-America, prospective case series with the sublingual vaccine, MV140, adds further clinical evidence to its safety and effectiveness in reducing recurrent UTIs in women.

An Effective Sublingual Vaccine, MV140, Safely Reduces Risk of Recurrent Urinary Tract Infection in Women.

Uncomplicated recurrent urinary tract infections (rUTIs) in women are associated with episodic bothersome symptoms and have a significant impact on the mental and physical quality of life. Treatment with antibiotics (short- and long-term dosing) results in acute and chronic side effects and costs and promotes general antibiotic resistance. Improved nonantibiotic management of rUTI in women represents a true, unmet medical need. MV140 is a novel sublingual mucosal-based bacterial vaccine developed for the prevention of rUTI in women. Based on observational, prospective, and randomized placebo-controlled studies, MV140 has been shown to safely prevent (or reduce the risk of) UTIs, reduce antibiotic use, overall management costs, and patient burden while improving the overall quality of life in women suffering from rUTIs.

Urologist-perceived barriers and perspectives on the underuse of sacral neuromodulation for overactive bladder in Canada.

INTRODUCTION: An estimated 18% of Canadians have overactive bladder (OAB), with approximately 24% of those reporting difficulty adhering to pharmacotherapy. To date, there has been no investigation into barriers facing sacral neuromodulation (SNM) as treatment for OAB in Canada. METHODS: Current Canadian Urological Association members were invited to participate in an anonymous survey. Data collected included open-ended and Likert scale responses addressing barriers to referral for SNM. Qualitative analysis used a Theoretical Domains Framework (TDF), while quantitative responses are reported using descriptive statistics. RESULTS: A response rate of 20.4% (n=142) was obtained. Most respondents believed SNM was underused (n=82, 57.7%) compared to only 6.3% (n=9) who believed it was used adequately. The most commonly cited reasons for not offering SNM were lack of availability (n=85, 59.9%), expertise (n=49, 34.5%), and funding (n=26, 18.3%). Participants were neutral regarding confidence to appropriately recommend SNM to patients (median 3, interquartile range [IQR] 2-4) and were not confident to manage patient care and issues related to SNM devices (median 2, IQR 1-3). On thematic analysis using the TDF, the most prevalent barriers to SNM care were related to infrastructure and resources. A lack of trained experts and lack of knowledge related to SNM use were also commonly identified barriers. CONCLUSIONS: In this first study exploring urologist-perceived barriers to SNM referral for medically refractory OAB in Canada, urologists acknowledge that SNM implantation is underused but did not feel confident in recommending SNM appropriately. A lack of trained experts and poor funding were also identified as major barriers to SNM referral.

Oral pharmacological treatments for chronic prostatitis/chronic pelvic pain syndrome: A systematic review and network meta-analysis of randomised controlled trials.

Background: Pharmacological treatments for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are empirically used. However, the quantitative comparative effectiveness and safety of multiple pharmacological treatments is lacking. Methods: PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to March 22, 2022. Randomised controlled trials comparing two or more oral pharmacological treatments for patients with CP/CPPS were included. Title, abstract, and full-text screening were independently screened by four reviewers. Primary outcomes were efficacy (the National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI] total score, pain score, urinary score, and quality of life score [QoL]) and safety (adverse events). This study was registered with PROSPERO, CRD42020184106. Findings: 25 studies (3514 patients) assessed 26 treatments. Low to very low quality evidence indicated that doxazosin (Mean difference [MD], -11.4, 95% Credible interval [CrI], -17.5 to -5.1) and the doxazosin, ibuprofen, and thiocolchicoside combination (MD, -11.6, CrI, -18.1 to -5.3) were significantly more effective than placebo in the NIH-CPSI total score. Other NIH-CPSI relative outcomes (pain, urinary, and QoL scores) showed a similar pattern. Low and very low quality evidence suggested that combination treatment including doxazosin, ibuprofen, and thiocolchicoside (odds ratios [OR], 3.2, CrI, 0.5 to 19.3) and the tamsulosin and dapoxetine combination (OR, 6.0, CrI, 0.7 to 67.3) caused more adverse events. In half of all comparisons regarding NIH-CPSI pain scores and quality of life scores, heterogeneity was minimal or low. Heterogeneity was high in both NIH-CPSI total symptom scores (I2  = 78.0%) and pain scores (I2  = 87. 0%) for tamsulosin versus placebo. There was also high heterogeneity in NIH-CPSI urine scores for the combination of tamsulosin and ciprofloxacin versus tamsulosin (I2  = 66.8%), tamsulosin and levofloxacin versus tamsulosin (I2  = 93.3%), and tamsulosin versus placebo (I2  = 83%). Interpretation: Pharmacological treatments have little evidence supporting efficacy in CP/CPPS. Future studies could personalise therapy for individuals according to specific symptoms and identify non-pharmacological targets for CP/CPPS. Funding: Dr Jiani Wu received funding for this project from the China Association for Science and Technology (2017QNRC001), the China Academy of Chinese Medical Sciences (ZZ13-YQ-027), and the National Natural Science Foundation of China (82105037).

The evolution of urethral stricture and urethroplasty practice over 15 years: A single-center, single-surgeon, 1319 urethroplasty analysis.

INTRODUCTION: The management of urethral stricture has evolved over the last several decades. We sought to analyze urethral stricture and urethroplasty trends at a tertiary referral center over a 15-year period. METHODS: Patients undergoing urethroplasty by a single surgeon from August 2003 to July 2018 were analyzed. Patient demographics, urethroplasty techniques, and outcomes were collected in a prospectively maintained database and were categorized into three five-year tertiles based on date of surgery. These tertiles were subsequently retrospectively analyzed for trends and changes in practice. RESULTS: A total of 1319 urethroplasties were completed over the study period. During the first five years (T1), 299 urethroplasties were performed, with 431 and 589 performed in T2 and T3, respectively. Mean overall patient age was 46.8 years, which increased significantly over time (p<0.001). Idiopathic strictures were most common (n=516, 39.1%) and unchanged over time, while proportionately radiation-induced strictures increased (n=9, 3.0% [T1], n=22, 5.1% [T2], n=51, 8.7% [T3]; p=0.001) as did iatrogenic and lichen sclerosus strictures. Mean stricture length (4.7 cm [T1], 4.8 cm [T2], 4.0 cm [T3]; p<0.001) and the mean number of prior endoscopic procedures (3.4 [T1], 3.9 [T2], and 2.5 [T3]; p<0.001] decreased over time. Single-stage urethroplasty with buccal mucosa was the most common technique performed (n=656, 49.7%) that increased in prevalence (p=0.009), while both flap and staged techniques decreased (p=0.008, p=0.004, respectively). Overall success rate was 90.1% (n=1106), which improved significantly with time (n=248, 86.7% [T1], n=359, 90.0% [T2], n=499, 93.4% [T3]; p=0.001). CONCLUSIONS: We observed that patients and treatment of urethral stricture evolved over 15 years in practice, with an increase in patient age, radiation, and iatrogenic and lichen sclerosus strictures, while demonstrating a decrease in stricture length and the number of prior endoscopic procedures performed. Increased use of single-stage urethroplasty using buccal mucosa was observed, which may have contributed to an increase in urethroplasty success over time.

Chronic prostatitis/chronic pelvic pain syndrome-related pain symptoms and their impact on sexual functioning.

INTRODUCTION: The present study sought to examine a new model to evaluate the mechanistic pathways between pain and sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), incorporating cognitive and emotional factors. METHODS: Men with a self-reported diagnosis of CP/CPPS (n=94, 24-69 years, Mage=44.22, standard deviation 11.25) were recruited through social media, support groups, and urology clinics and completed an online questionnaire of demographic, pain, cognitive, psychological, and sexual variables. Descriptive statistics, correlation analysis, and serial mediation analyses assessed variable associations. RESULTS: Almost half of participants reported mild to severe erectile dysfunction (47.4%). Sexual dysfunction was associated with greater pain symptom severity and pain catastrophizing, as well as depressive symptoms (p<0.01 for all). While pain did not independently predict levels of sexual dysfunction, the addition of pain catastrophizing and depressive symptoms into the pathway explained the association between increased pain symptoms and decreased sexual functioning (p<0.01). CONCLUSIONS: Beyond generally poor sexual functioning in the current sample, it appears as if cognitive and emotional factors play a role in the association between pain symptoms and sexual functioning in these men with CP/CPPS. The findings of how pain catastrophizing and depression impact the association of pain severity and decreased sexual functioning is important for improving patient care.

Development of New Comorbidities in Patients Awaiting Urinary Incontinence Surgery Following Radical Prostatectomy.

OBJECTIVE: To examine the incidence and factors associated with the development of new comorbidities in men undergoing anti-incontinence surgery after prostate cancer (PCa) surgery. Post-prostatectomy incontinence (PPI) may deter men from engaging in physical activities and increase the risk of developing comorbidities after prostatectomy. METHODS: Patients undergoing surgery for PPI from 2006 to 2019 were identified. A retrospective review was performed to document patient characteristics noted at the time of PCa surgery and compare these with parameters recorded at the time of anti-incontinence surgery. RESULTS: A total of 229 patients were included. Mean age was 68.8 years at time of incontinence surgery. Median duration of incontinence was 3.5 ± 4.6 years. There was a significant increase in CCI comorbidities between PCa surgery and PPI surgery (2.7 ± 1.5 vs 4.1 ± 1.9, P < .0001). Almost half of patients (45.2%) developed a new comorbidity while awaiting incontinence surgery including an increase in the incidence of diabetes (21.9% vs 12.7%; p<0.0001), hypertension (56.2% vs 36.7%; P < .0001), coronary artery disease (14.6% vs 8.9%; P = .008) and arrhythmia (11.0% vs 3.8%; P = .008). On multivariable analysis, duration of incontinence was significantly associated with development of new comorbidities (O.R. 1.2, P = .01) while age (P = .20) and incontinence severity (P = 1.0) were not. There was no change in weight (P = .34), obesity (P = 1.0) or BMI (P = .18) between PCa surgery and PPI surgery. CONCLUSION: Patients with PPI appear at risk of developing new comorbidities while awaiting anti-incontinence surgery. Strategies which expedite return of continence for example, early surgical intervention, may facilitate resumption of physical activity and minimize the risk of future comorbidity.

The bacterial microbiota of Hunner lesion interstitial cystitis/bladder pain syndrome.

OBJECTIVE: To undertake the first comprehensive evaluation of the urinary microbiota associated with Hunner lesion (HL) interstitial cystitis/bladder pain syndrome (IC/BPS). Despite no previous identification of a distinct IC/BPS microbial urotype, HL IC/BPS, an inflammatory subtype of IC/BPS, was hypothesized most likely to be associated with a specific bacterial species or microbial pattern. PARTICIPANTS AND METHODS: The bacterial microbiota of midstream urine specimens from HL IC/BPS and age- and gender-matched IC/BPS patients without HL (non-HL IC/BPS) were examined using the pan-bacterial domain clinical-level molecular diagnostic Pacific Biosciences full-length 16S gene sequencing protocol, informatics pipeline and database. We characterized the differential presence, abundances, and diversity of species, as well as gender-specific differences between and among HL and non-HL IC/BPS patients. RESULTS: A total of 59 patients with IC/BPS were enrolled (29 HL, 30 non-HL; 43 women, 16 men) from a single centre and the microbiota in midstream urine specimens was available for comparison. The species abundance differentiation between the HL and non-HL groups (12 species) was not significantly different after Bonferroni adjustments for multiple comparisons. Similarly, the nine differentiating species noted between female HL and non-HL patients were not significantly different after similar statistical correction. However, four species abundances (out of the 10 species differences identified prior to correction) remained significantly different between male HL and non-HL subjects: Negativicoccus succinivorans, Porphyromonas somerae, Mobiluncus curtisii and Corynebacterium renale. Shannon diversity metrics showed significantly higher diversity among HL male patients than HL female patients (P = 0.045), but no significant diversity differences between HL and non-HL patients overall. CONCLUSIONS: We were not able to identify a unique pathogenic urinary microbiota that differentiates all HL from all non-HL IC/BPS. It is likely that the male-specific differences resulted from colonization/contamination remote from the bladder. We were not able to show that bacteria play an important role in patients with HL IC/BPS.

Biopsychosocial predictors of suicide risk in patients with interstitial cystitis/bladder pain syndrome.

INTRODUCTION: The impact of interstitial cystitis/bladder pain syndrome (IC/BPS) is prevalent and severe. Studies examining the IC/BPS prevalence and predictors of suicide risk are limited by their lack of theoretically relevant suicide research variables. This research reports suicide risk prevalence and its biopsychosocial predictors for a community IC/BPS sample. METHODS: Self-identified female patients suffering from IC/BPS (n=813; 18-80 years, mean 46.60, standard deviation [SD] 14.10) recruited from online IC/BPS support groups completed measures of demographic, pain, symptoms, and psychosocial variables. Descriptive statistics, correlations, and multivariable logistic regressions examined prevalence, variable associations, and suicide risk prediction. RESULTS: Suicide risk prevalence was 38.1%. Suicide risk was associated with greater odds for exposure to suicide, psychache, hopelessness, and perceived burdensomeness to others. Further, examining suicide risk by levels of pain showed that exposure to suicide and hopelessness were consistent suicide risk predictors across pain levels; psychache for lower levels of pain, depression in moderate levels of pain, and perceived burdensomeness in moderate and severe pain levels. CONCLUSIONS: The high prevalence of suicide risk is alarming and signifies an imperative for recognizing this risk within the IC/BPS population. The identified psychosocial risk factors may be used in refining screening and treatment, and in directing future IC/BPS research.

Determining Perioperative Practice Patterns in Urethroplasty: A Survey of Genitourinary Reconstructive Surgeons.

OBJECTIVE: To better delineate perioperative urethroplasty practice patterns among reconstructive urologists given that management strategies in reconstructive urology have generally been poorly described. METHODS: An online survey examining perioperative management of anterior urethroplasty patients was administered to Society of Genitourinary Reconstructive Surgeons (GURS) members between August-October 2019. Questions pertained to tissue transfer, pharmacologic prophylaxis, catheter use, follow-up, and post-operative care. RESULTS: A total of 248 GURS members were invited to participate, with a response rate of 57.2% (n = 142). Most participants performed >20 urethroplasties per year (n = 108, 76.1%). Almost all respondents (97.9%, n = 139) used intraoperative intravenous antibiotics. A minority of surgeons used intraoperative pharmacologic thromboembolism prophylaxis (n = 57, 40.1%). Surgeons prefer buccal mucosa for grafting (n = 138, 97.2%) with many leaving the donor site open (n = 76, 53.5%). Only 21.8% (n = 31) of surgeons prescribe bedrest for patients and 25.4% (n = 36) routinely place drains. Postoperatively, oral antimicrobials are routinely administered (n=100, 70.4%), with most continuing until the urinary catheter is removed (70, 72.2%). Patients commonly had a urethral catheter for 2-3 (n = 72, 58.5%) or 3-4 weeks (n = 37, 30.1%). At catheter removal, surgeons routinely perform urethral imaging with contrast (n=96, 67.6%). Most surgeons prefer some form of objective investigation (n = 111, 78.2%) (uroflowmetry [n = 91, 82.0%], post-void residual [n = 88, 79.3%]). Cystoscopy is also commonly performed (n = 64, 57.7%). These investigations are routinely performed at 2-3 (n = 49, 44.2%) or 4-6 months (n = 38, 34.2%) postoperatively. CONCLUSION: Despite general consensus on urethroplasty management options, heterogeneity remains in the areas of antibiotic use, VTE prophylaxis, donor site management, catheter management, and follow-up assessment.

The chicken or the egg: Longitudinal changes in pain and catastrophizing in women with interstitial cystitis/bladder pain syndrome.

INTRODUCTION: Evidence-based psychological strategies are being used as clinicians look for helpful interventions for patients diagnosed with the enigmatic chronic urological pelvic pain condition of interstitial cystitis/bladder pain syndrome (IC/BPS). Pain and pain catastrophizing are associated with chronic pelvic pain outcomes but the longitudinal role of catastrophizing on patient pain in IC/BPS remains unknown. METHODS: Women with IC/BPS were recruited from tertiary care clinics across North America and completed a battery of questionnaires, including demographics, pain, depression, catastrophizing at baseline, six months, and one year. RESULTS: A total of 226 patients completed baseline questions, 183 completed the six-month survey, and 151 completed the one-year survey. Using a cross-lagged analysis, early changes in pain catastrophizing predicted later changes in pain, but not vice versa. Followup subscale analyses revealed that early changes in magnification predicted later changes in pain, early changes in pain predicted later changes in rumination, and that there was a recursive relationship between changes in helplessness and changes in pain across the study. CONCLUSIONS: Pain catastrophizing should be considered a prime target in psychological treatment for chronic pain in patients with IC/BPS, particularly those thinking styles associated with pain onset and maintenance. Future research should be conducted with constructs such as pain catastrophizing in samples prioritizing diversity of patients with IC/BPS and mechanisms as to how to effectively decrease catastrophizing.

No Outcome Differences after Cystectomy between Patients with De Novo Muscle-Invasive Bladder Cancer Compared to Progressors: A Retrospective Population-Based Study.

PURPOSE: Whether patients who progress to muscle-invasive bladder cancer have worse outcomes compared to those that present de novo is important for clinical decision making. The objective of this study was to determine if there is a difference in survival after radical cystectomy for de novo cases compared to progressors. MATERIALS AND METHODS: This retrospective, population-based study reports on all patients who underwent radical cystectomy in Ontario utilizing records linked to the Ontario Cancer Registry. The primary objective was to determine if survival was associated with presentation. Secondary objectives included describing processes-of-care between the cohorts and investigate differential responses to chemotherapy. Cox proportional-hazards regression models were used to adjust for known confounders. RESULTS: Between 2009 and 2013, 1,573 patients underwent radical cystectomy with 893 in the de novo cohort while 680 were identified as progressors. After adjusting by stage prior to cystectomy, several processes of care indicators and early outcomes were comparable between the cohorts. In adjusted analysis there were no differences in outcomes; compared to the reference de novo presentation, the hazards ratios (95% confidence interval) for progressors were 0.98 (0.85-1.14) for cancer-specific survival and 1.0 (0.88-1.10) for overall survival. There was no effect modification of chemotherapy based on presentation for cancer-specific survival. Lack of information about those progressors that never received cystectomy is a major limitation. CONCLUSIONS: When controlled for stage, no clinically significant differences in survival outcomes were identified between bladder cancer patients undergoing cystectomy presenting with de novo muscle-invasive bladder cancer compared to progressors in routine clinical practice.

The scope, presentation, and management of genitourinary complications in patients presenting with high-grade urethral complications after radiotherapy for prostate cancer.

INTRODUCTION: The scope of complications arising after radiotherapy (RT) treatment for prostate cancer is under-recognized and not well-described. The objective of this study is to describe the presentation, scope, and management of genitourinary (GU) complications in patients referred for high-grade urethral complications or sphincter weakness incontinence after prostate RT. METHODS: A retrospective review was performed of patients referred to a reconstructive urologist for management of grade 4 urethral complications and sphincter weakness incontinence after prostate RT from December 2004 to December 2015. Patients' signs, symptoms, complications, and treatments are described. RESULTS: A total of 120 patients were identified, with a mean age of 67.8 years; 55.8% (n=67) received external beam radiotherapy (EBRT), 38.3% (n=46) brachytherapy (BT), and 5.8% (n=7) combination RT. The mean time to first complication after RT was 57.7 months (1-219) and number of complications per patient was 5.1±2.2. The most common associated complications were urethral stenosis (n=106, 88.3%), sphincter weakness urinary incontinence (n=55, 45.8%), radiation cystitis (n=61, 50.8%), refractory storage lower urinary tract symptoms (n=106, 88.3%), GU pain (n=28, 23.3%), and prostate necrosis/abscess (n=17, 14.2%). Patients required a mean of 7.4±4.4 treatments over a 33-month period, including urethral dilation/urethrotomy (n= 93, 77.5%), urethroplasty (n=53, 44.2%), transurethral resection (n=52, 43.3%), cystolithopaxy (n=14, 11.7%), artificial urinary sphincter (n=8, 6.7%), and urinary diversion (n=8, 6.7%). Patients with RT combined with other modalities had more complications (6.2 vs. 4.2, p=0.001), higher rates of incontinence (93.8% vs. 29.5%, p=0.001), necrosis (31.3% vs. 8.0%, p=0.003), erectile dysfunction (84.4% vs. 51.1%, p=0.001), and hematuria (59.4% vs. 36.4%, p=0.04). CONCLUSIONS: Urethral complications related to prostate RT are seldom an isolated problem and require a substantial amount of urological resources and interventions.