There is limited data on best practices for intravesical botulinum toxin (BoNT) including pre-procedure patient evaluation, standard operative procedures, and appropriate follow-up. The primary objective of this study is to characterize the intravesical BoTN practice patterns of Canadian urologists via a comprehensive online survey. We hypothesize that Canadian urologists will vary widely with regards to evaluation, administration, and follow-up. Secondary objectives are to identify barriers to intravesical BoTN administration as well as to assess for differences in practice patterns between providers with formal fellowship training in functional urology and those without.

An anonymous, web-based, bilingual survey was administered to all practicing Canadian urologists using the LimeSurvey platform (www.limesurvey.org).  Urology residents, fellows, or Canadian urologists who do not practice in Canada were excluded. Respondents who provide intravesical botulinum toxin were questioned on training, surgical volume, work-up, technique, and follow-up practices. Practices for those with formal training in functional urology were compared to those without using the Chi-square test for nominal and Mann Whitney U test for ordinal variables. .  Barriers to treatment delivery were identified.

The overall response rate was 26% (148/570). Most providers (59%) perform one to 10 treatments/month. Pre-operatively, 51% perform cystoscopy, and 43% perform urodynamics. A majority (66%) give routine antimicrobial prophylaxis; however, regimen and duration varied. Most (79%) perform some treatments under local anaesthetic, and 66% instill lidocaine solution for analgesia. There was a wide variation in technique with regards to the number of injections administered (range <10 to >20), volume administered per injection (range 0.5mL to 2mL), location of injections (bladder body vs. trigone vs. both), and depth of injection. Post-operative follow-up ranged from 3 days to 3 months. Respondents with fellowship training in functional/reconstructive urology performed more treatments per month and administered fewer injections per treatment. Common barriers to delivery included lack of experience/training among non-providers (45%), lack of resources (34%), and lack of medication funding (32%).

Intravesical BoNT is a widely accepted and administered treatment for patients with refractory OAB and NLUTD. Due to an overall lack of high-quality evidence for proper assessment and administration, there remains a wide-variation in practice patterns amongst Canadian urologists. Through addressing some of the identified barriers to delivery, we hope to improve the quality of care for patients with OAB and NLUTD.

Further study is required to identify optimal pre-procedure evaluation, intra-procedure administration, and post-procedure follow-up practices for patients undergoing intravesical botulinum toxin injections. The results of this survey can be used to guide future prospective studies with an aim to optimize the efficacy, efficiency, safety, and accessibility of intravesical BoNT administration.