Skip to main content

Transitional Urology

Transitional urology is the subspecialty bridging pediatric and adult urologic care for patients with congenital or acquired genitourinary conditions requiring lifelong management. It encompasses the structured process by which adolescents and young adults (AYAs) assume increasing responsibility for their own health care, transfer from pediatric to adult providers, and receive ongoing surveillance for condition-specific complications.[1][2] With improved survival, more individuals with complex congenital anomalies are reaching adulthood than ever before, creating an urgent need for dedicated adult expertise in conditions historically managed only by pediatric urologists.[3][4]

Definition and Scope​

Transition is distinct from transfer: transition is the longitudinal process of preparing the patient for adult-centered care, while transfer is the discrete event of moving to an adult provider.[5] The International Children's Continence Society (ICCS) position statement emphasizes that transition should begin in early adolescence and address medical, psychosocial, educational, and vocational needs.[5]

Core conditions requiring transitional urologic care:[2][6][7]

  • Neurogenic bladder (spina bifida, spinal cord injury, tethered cord)
  • Posterior urethral valves (PUV)
  • Bladder exstrophy-epispadias complex (BEEC)
  • Disorders / differences of sex development (DSD)
  • Hypospadias (particularly proximal / complex)
  • Anorectal malformations (cloacal anomalies)
  • Prune belly syndrome
  • Vesicoureteral reflux and CAKUT (congenital anomalies of the kidney and urinary tract)
  • Patients with augmentation cystoplasty, continent diversions, or catheterizable channels

Universal Goals​

Regardless of the underlying condition, the overarching objectives are:[2][6][7]

  1. Preservation of renal function — the single most important lifelong goal.
  2. Optimization of lower urinary tract function — safe storage and drainage.
  3. Urinary continence — critical for social participation, employment, and quality of life.
  4. Sexual function and fertility — addressed proactively starting in adolescence.
  5. Surveillance for long-term surgical complications — especially after augmentation cystoplasty or diversion.
  6. Malignancy monitoring — in augmented bladders and retained gonads (DSD).
  7. Psychosocial well-being and independence — self-management, mental health, vocational planning.

The Transition Process​

When to Start​

The AAP, AAFP, and ACP joint clinical report ("Got Transition") recommends initiating transition planning at age 12–14, with transfer typically occurring between ages 18 and 25 depending on developmental readiness and medical stability.[8] The Spina Bifida Association (SBA) 2023 guidelines provide age-stratified recommendations beginning in early adolescence.[9]

Transition Readiness Assessment​

Several validated tools exist; none has demonstrated clear superiority:[8][10][11]

  • Transition Readiness Assessment Questionnaire (TRAQ) — most widely used; generic.
  • TRAQ-SB — spina bifida-specific version, validated up to age 25.[9]
  • Good2Go Questionnaire — evaluates self-advocacy, knowledge, self-care, and social support.[12]
  • TRxANSITION Scale, RTQ, and Got Transition tools.[10]

A structured urologic transitional care program using the Good2Go tool demonstrated significant improvements in knowledge readiness (+12.78 points, P = 0.005) and reductions in ER visits and admissions compared to standard care.[12]

Structured Transition Programs​

A systematic review of 20 studies found that structured transition programs with dedicated multidisciplinary clinics were associated with improved patient adherence and fewer emergency visits. Psychosocial readiness and family involvement were the primary predictors of successful transition. Key barriers include inadequate patient education, lack of transition coordinators, limited adult care access, and financial constraints.[1]

A 9-year evaluation of a staged transition clinic for congenital neurogenic bladder demonstrated that 96.2% of patients ready to transition successfully transferred to adult care, and 72.4% remained active in follow-up — compared with only 36.8% of patients who initiated adult care without structured transition (P < 0.001).[13]

Condition-Specific Considerations​

Spina Bifida / Neurogenic Bladder​

The most common condition requiring transitional urology. Adult management issues:[2][14][15][16]

  • Ongoing CIC and anticholinergic management — bladder dynamics can change with growth, puberty, and aging; urodynamic reassessment is often needed.
  • Renal surveillance — proteinuria screening, serum creatinine monitoring, upper-tract imaging; ACE inhibitors for progressive CKD.
  • Augmentation cystoplasty complications — metabolic acidosis, stone formation, UTIs, perforation risk, and malignancy surveillance (see below).
  • Bowel management — fecal incontinence rated as the biggest issue by 50% of parents; continence is a major factor in social participation and employment.[9][15]
  • Sexual health — dissatisfaction with sexual function is common; proactive counseling about fertility, contraception, and pregnancy planning is essential.[9]
  • Latex allergy — high prevalence; must be documented and communicated to adult providers.
  • Shunt management — adult neurosurgery referral for VP shunt concerns.[9]

The SBA 2023 guidelines recommend a hand-off packet including medical summary, action plans for common complications (shunt malfunction, UTI, constipation, skin ulcers), and supply / equipment information.[9]

Posterior Urethral Valves (PUV)​

PUV is the most common cause of obstructive uropathy in males. Approximately 15–23% develop end-stage renal disease (ESRD), with a lifetime risk of 28.5%. Critically, no patient in one large cohort developed ESRD after age 34, suggesting a finite window of vulnerability.[17][18]

Adult issues:

  • Progressive CKD — median eGFR decline of 2.6 mL/min/1.73 m²/year continues into adulthood; proteinuria and recurrent UTIs are associated with faster progression.[17]
  • "Valve bladder" syndrome — persistent bladder dysfunction (myogenic failure, poor compliance, high-pressure chronic retention) occurs in 38% of adults and may worsen at puberty.[19]
  • Sexual function — erectile dysfunction is rare; 12.5% report ejaculatory dysfunction.[19]
  • Fertility — generally preserved, though lower paternity rates are reported.
  • A dedicated multidisciplinary PUV clinic with standardized proactive management reduced CKD progression (12% vs. 27%, P = 0.02) and need for kidney replacement therapy (3% vs. 20%, P < 0.05).[20]

Bladder Exstrophy-Epispadias Complex (BEEC)​

Adults with BEEC face unique challenges related to continence, genital anatomy, sexual function, and fertility:[21][22][23][24][25]

  • Continence — achieved in ~83% diurnally, but often requires multiple procedures (76% need >1 continence surgery).[25]
  • Sexual function in males — erectile function preserved in 55–79%; penile length is shorter and dorsal chordee is common; 63–73% report satisfactory sexual activity.[21][22][24]
  • Sexual function in females — comparable to controls on FSFI; introitoplasty may be needed in ~25%.[21][25]
  • Male fertility — significantly impaired; oligoasthenoteratozoospermia in ~71%, low ejaculate volume (mean 0.4 cc), and retrograde ejaculation are common. Only 22–32% achieve paternity, often requiring ART. Early sperm banking should be discussed.[22][24][26]
  • Female fertility — generally preserved; pregnancy is possible but requires specialized obstetric management (cesarean delivery often recommended due to pelvic anatomy).[27]
  • Psychosocial — 35% have not become sexually active (vs. 11% controls); high education levels but delayed social milestones.[21]

Hypospadias​

Long-term follow-up reveals significant adult implications of childhood hypospadias repair:[28][29][30]

  • Reintervention rate — 39% require at least one reoperation; proximal hypospadias and repair before 12 months are risk factors.[28]
  • Suboptimal urinary or sexual outcomes in 53% of adolescents / young adults at long-term follow-up.[28]
  • Urethral stricture is the most common adult presentation (47% of those with prior childhood repair), with strictures significantly longer than in unoperated patients.[30]
  • Adult reoperation with two-stage buccal mucosa graft urethroplasty achieves 83% initial success rates.[31][32]
  • LUTS (weak stream, dribbling, spraying) are twice as common as in controls; paternity rates are lower (24% vs. 29%).[29]

Disorders / Differences of Sex Development (DSD)​

Transition in DSD is particularly complex due to the intersection of medical, psychological, and identity-related needs:[33][34][35]

  • Hormone replacement — lifelong testosterone or estradiol replacement for gonadal deficiency; glucocorticoid / mineralocorticoid replacement in CAH.
  • Gonadal tumor surveillance — risk varies by karyotype and gonad type; retained dysgenetic gonads require monitoring.
  • Fertility preservation — should be addressed in adolescence; close collaboration between endocrinology, urology / gynecology, and reproductive medicine.[34][36]
  • Psychosocial support — cornerstone of DSD management; loss to follow-up after pediatric care is a major problem, with patients frequently unable to find specialized adult providers.[35]
  • Multidisciplinary teams are recommended at all ages, including pediatric endocrinology, genetics, psychology, urology, and gynecology.[36][35]

Augmentation Cystoplasty: Lifelong Surveillance​

Patients with augmentation cystoplasty (most commonly for neurogenic bladder or exstrophy) require lifelong follow-up for multiple complications:[37][38][39]

  • Metabolic complications — hyperchloremic metabolic acidosis, vitamin B12 deficiency (ileal segments), electrolyte disturbances; annual basic metabolic panel recommended.[39]
  • Urinary tract infections — chronic bacteriuria is universal; symptomatic UTIs require treatment.
  • Stone formation — related to mucus production, stasis, and metabolic changes.
  • Perforation — life-threatening; patients must know warning signs (abdominal pain, fever, peritonitis).
  • Malignancy risk — the most debated long-term concern:
    • Incidence ranges from 0–5.5%, with mean latency of 19–20 years from surgery.[37][38]
    • Adenocarcinoma is the most common histologic type (52%), predominantly at the entero-urinary anastomosis.[37][40]
    • Tumors are often diagnosed at advanced stage with poor prognosis (1-year survival 56%).[38]
    • Whether augmentation itself is an independent risk factor (vs. the underlying congenital bladder abnormality) remains debated — one matched cohort found no significant difference in cancer incidence between augmented and non-augmented patients (4.6% vs. 2.6%, P = 0.54).[41]
    • Immunosuppression (e.g., post-renal transplant) is an independent risk factor for malignancy in this population (15% vs. 2.8%, P = 0.03).[41]
    • The AUA / SUFU guideline recommends annual surveillance with focused history, physical exam, basic metabolic panel, and urinary-tract imaging for all patients with bowel-incorporating reconstructions.[39]
    • The role of routine cystoscopy is controversial — one long-term surveillance study found no malignancies over 15 years of annual endoscopy and cytology, leading the authors to question routine endoscopic surveillance. Others advocate cystoscopy beginning 10 years after augmentation.[42][43]
    • Urine FISH has shown promising specificity (95%) and sensitivity (100%) for malignancy screening, though data are limited.[44]
    • Molecular profiling reveals mutations similar to gastrointestinal adenocarcinomas (TP53, KRAS, MYC), with potentially targetable alterations (ATM, BRCA1, EGFR, ERBB2) in the majority of cases.[45]

Models of Care​

The AUA Working Group on Genitourinary Congenitalism (2015) emphasized that management of complex congenital urologic disease in adults is difficult due to the lack of long-term data, and recommended consensus-based approaches with providers spanning the life course.[27] Key models include:

  • Dedicated transitional urology clinics — joint pediatric-adult clinics where patients are seen by both teams simultaneously during the transition period; associated with the best adherence outcomes.[1][13]
  • Specialist adult congenital urology centers — concentrated expertise for rare conditions; the European Urology consensus recommends specialist centers as the most effective and safe model.[3]
  • Multidisciplinary teams — urology, nephrology, neurosurgery, physiatry, psychology, social work, and transition coordinators.[1][9]
  • Digital health solutions — emerging tools for remote monitoring, patient education, and telehealth follow-up to address geographic disparities.[1]

When patients are referred to a tertiary transitional care center, management is altered in 71% of cases, with 58% requiring surgical intervention (augmentation, diversion, botulinum toxin, stone surgery) — underscoring the complexity of these patients and the need for specialized adult expertise.[46]

Barriers to Successful Transition​

CategoryExamples
Patient / familyLow health literacy, desire for normalcy, reluctance to leave familiar pediatric team, cognitive impairment
ProviderLimited adult-urologist training in congenital conditions, unfamiliarity with reconstructed anatomy
SystemLack of transition coordinators, insurance gaps (aging out of pediatric coverage), geographic disparities, no standardized protocols
PsychosocialMental-health comorbidities, social isolation, delayed autonomy, inadequate vocational support

Key Recommendations Summary​

  • Begin transition planning at age 12–14 using validated readiness-assessment tools; conduct part of each visit without parents present.[8][9]
  • Establish a multidisciplinary transition team including a dedicated transition coordinator.[1][9]
  • Prepare a comprehensive hand-off packet with medical / surgical history, current management plans, action plans for common complications, and supply / equipment needs.[9]
  • Transfer during medical and social stability — avoid transfer during acute illness, major surgery, or psychosocial crisis.[10]
  • Ensure lifelong surveillance — renal function, bladder dynamics, metabolic parameters, and malignancy screening as indicated by the specific condition and surgical history.[2][3][39]
  • Address sexual health and fertility proactively — these are consistently identified as unmet needs across all congenital urologic conditions.[2][47][24]
  • Recognize that adult management frequently differs from childhood — bladder dynamics change with growth and aging, new complications emerge, and surgical needs evolve.[4][46]

Cross-references​

References​

1. Akdağcık Z, Soytürk S, Sılay MS, et al. "Transitional Urology in Congenital and Neurological Conditions: A Global Review of Structured Care Models and Clinical Outcomes." World J Urol. 2025;43(1):628. doi:10.1007/s00345-025-06021-5

2. Peycelon M, Misseri R. "The Basics of Transition in Congenital Lifelong Urology." World J Urol. 2021;39(4):993-1001. doi:10.1007/s00345-020-03116-z

3. Wood D, Baird A, Carmignani L, et al. "Lifelong Congenital Urology: The Challenges for Patients and Surgeons." Eur Urol. 2019;75(6):1001-1007. doi:10.1016/j.eururo.2019.03.019

4. Woodhouse CR, Neild GH, Yu RN, Bauer S. "Adult Care of Children From Pediatric Urology." J Urol. 2012;187(4):1164-1171. doi:10.1016/j.juro.2011.12.011

5. Bower WF, Christie D, DeGennaro M, et al. "The Transition of Young Adults With Lifelong Urological Needs From Pediatric to Adult Services: An International Children's Continence Society Position Statement." Neurourol Urodyn. 2017;36(3):811-819. doi:10.1002/nau.23039

6. Lambert SM. "Transitional Care in Pediatric Urology." Semin Pediatr Surg. 2015;24(2):73-78. doi:10.1053/j.sempedsurg.2015.01.004

7. Wiener JS, Huck N, Blais AS, et al. "Challenges in Pediatric Urologic Practice: A Lifelong View." World J Urol. 2021;39(4):981-991. doi:10.1007/s00345-020-03203-1

8. Meyers MJ, Irwin CE. "Health Care Transitions for Adolescents." Pediatrics. 2023;151(Suppl 1):e2022057267L. doi:10.1542/peds.2022-057267L

9. Fremion E, Kaufman M, Mukherjee S, Murphy P, Smith K. "2023 Updates to the Spina Bifida Transition to Adult Care Guidelines." J Pediatr Rehabil Med. 2023;16(4):583-593. doi:10.3233/PRM-230052

10. Kidney Disease: Improving Global Outcomes (KDIGO) Guideline Workgroup. "KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease." Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018

11. Yi T, Hu Y, Xia L, et al. "Instruments to Assess Transition Readiness Among Adolescents With Chronic Disease: A COSMIN Systematic Review of Measurement Properties." Child Care Health Dev. 2025;51(1):e70017. doi:10.1111/cch.70017

12. Chua ME, Lee SY, Tanaka S, Hearld KR, Lemak CH. "The Impact of Urologic Transitional Care Program on Change in Transition Readiness and Healthcare Resource Utilization Among Adolescent Patients With Congenital Urogenital Conditions Needing Lifelong Care." Pediatr Surg Int. 2026;42(1):62. doi:10.1007/s00383-025-06281-7

13. Blubaum A, Lewis J, Frimberger D, Slobodov G. "9-Year Evaluation of a Transitional Care Program for Congenital Neurogenic Bladder Patients." Urology. 2023;180:285-290. doi:10.1016/j.urology.2023.06.023

14. Snow-Lisy DC, Yerkes EB, Cheng EY. "Update on Urological Management of Spina Bifida From Prenatal Diagnosis to Adulthood." J Urol. 2015;194(2):288-296. doi:10.1016/j.juro.2015.03.107

15. Iskandar BJ, Finnell RH. "Spina Bifida." N Engl J Med. 2022;387(5):444-450. doi:10.1056/NEJMra2116032

16. Brownrigg N, Lorenzo AJ, Rickard M, Dos Santos J. "The Urological Evaluation and Management of Neurogenic Bladder in Children and Adolescents." Pediatr Nephrol. 2024;39(2):409-421. doi:10.1007/s00467-023-06064-z

17. Huang VW, Behairy M, Abelson B, et al. "Kidney Disease Progression in Pediatric and Adult Posterior Urethral Valves (PUV) Patients." Pediatr Nephrol. 2024;39(3):829-835. doi:10.1007/s00467-023-06128-0

18. Heikkilä J, Holmberg C, Kyllönen L, Rintala R, Taskinen S. "Long-Term Risk of End Stage Renal Disease in Patients With Posterior Urethral Valves." J Urol. 2011;186(6):2392-2396. doi:10.1016/j.juro.2011.07.109

19. Çetin B, Dönmez Mİ, Erdem S, Ziylan O, Oktar T. "Renal, Bladder and Sexual Outcomes in Adult Men With History of Posterior Urethral Valves Treated in Childhood." Urology. 2021;153:301-306. doi:10.1016/j.urology.2020.11.002

20. Rickard M, Lorenzo AJ, Robinson C, et al. "Impact of a Standardized Care Pathway and a Dedicated Multidisciplinary Posterior Urethral Valve Clinic on 5-Year Kidney and Bladder Outcomes." Pediatr Nephrol. 2025. doi:10.1007/s00467-025-06864-5

21. Suominen JS, Santtila P, Taskinen S. "Sexual Function in Patients Operated on for Bladder Exstrophy and Epispadias." J Urol. 2015;194(1):195-199. doi:10.1016/j.juro.2015.01.098

22. Rubenwolf P, Thomas C, Thüroff JW, Stein R. "Sexual Function, Social Integration and Paternity of Males With Classic Bladder Exstrophy Following Urinary Diversion." J Urol. 2016;195(2):465-470. doi:10.1016/j.juro.2015.08.076

23. Zhu X, Klijn AJ, de Kort LMO. "Urological, Sexual, and Quality of Life Evaluation of Adult Patients With Exstrophy-Epispadias Complex: Long-Term Results From a Dutch Cohort." Urology. 2020;136:272-277. doi:10.1016/j.urology.2019.10.011

24. Reynaud N, Courtois F, Mouriquand P, et al. "Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex." J Sex Med. 2018;15(3):314-323. doi:10.1016/j.jsxm.2018.01.004

25. Sinatti C, Waterschoot M, Roth J, et al. "Long-Term Sexual Outcomes in Patients With Exstrophy-Epispadias Complex." Int J Impot Res. 2021;33(2):164-169. doi:10.1038/s41443-020-0248-2

26. Ben-Chaim J, Jeffs RD, Reiner WG, Gearhart JP. "The Outcome of Patients With Classic Bladder Exstrophy in Adult Life." J Urol. 1996;155(4):1251-1252.

27. Eswara JR, Kielb S, Koyle MA, Wood D, Wood HM. "The Recommendations of the 2015 American Urological Association Working Group on Genitourinary Congenitalism." Urology. 2016;88:1-7. doi:10.1016/j.urology.2015.11.019

28. Tack LJW, Springer A, Riedl S, et al. "Adolescent and Young Adult Urogenital Outcome Following Childhood Hypospadias Repair: Perfection Revisited." J Urol. 2021;206(3):734-744. doi:10.1097/JU.0000000000001869

29. Diamond DA, Chan IHY, Holland AJA, et al. "Advances in Paediatric Urology." Lancet. 2017;390(10099):1061-1071. doi:10.1016/S0140-6736(17)32282-1

30. Hoy NY, Rourke KF. "Better Defining the Spectrum of Adult Hypospadias: Examining the Effect of Childhood Surgery on Adult Presentation." Urology. 2017;99:281-286. doi:10.1016/j.urology.2016.07.057

31. Morrison CD, Cinà DP, Gonzalez CM, Hofer MD. "Surgical Approaches and Long-Term Outcomes in Adults With Complex Reoperative Hypospadias Repair." J Urol. 2018;199(5):1296-1301. doi:10.1016/j.juro.2017.11.078

32. Aldamanhori RB, Osman NI, Inman RD, Chapple CR. "Contemporary Outcomes of Hypospadias Retrieval Surgery in Adults." BJU Int. 2018;122(4):673-679. doi:10.1111/bju.14355

33. Nordenström A, Mangone A, Mantovani G. "Hormone Replacement in Disorders of Sex Development, and Long-Term Effects." Best Pract Res Clin Endocrinol Metab. 2025:102022. doi:10.1016/j.beem.2025.102022

34. Nowotny HF, Reisch N. "Challenges Waiting for an Adult With DSD." Horm Res Paediatr. 2023;96(2):207-221. doi:10.1159/000527433

35. Cools M, Nordenström A, Robeva R, et al. "Caring for Individuals With a Difference of Sex Development (DSD): A Consensus Statement." Nat Rev Endocrinol. 2018;14(7):415-429. doi:10.1038/s41574-018-0010-8

36. Claahsen-van der Grinten HL, van Herwaarden A, Kempers M, et al. "Approach to the Patient: Comprehensive Multidisciplinary Care for Adolescents With Difference in Sex Development (DSD)." J Clin Endocrinol Metab. 2026;111(4):e1183-e1194. doi:10.1210/clinem/dgag023

37. Biardeau X, Chartier-Kastler E, Rouprêt M, Phé V. "Risk of Malignancy After Augmentation Cystoplasty: A Systematic Review." Neurourol Urodyn. 2016;35(6):675-682. doi:10.1002/nau.22775

38. Garnier S, Vendrell J, Boillot B, et al. "Malignancy After Augmentation Enterocystoplasty: A Nationwide Study of Natural History, Prognosis and Oncogene Panel Analysis." J Urol. 2020;204(1):136-143. doi:10.1097/JU.0000000000000752

39. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA / SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up." J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

40. Anderson JA, Matoso A, Murati Amador BI, et al. "Invasive Poorly Differentiated Adenocarcinoma of the Bladder Following Augmentation Cystoplasty: A Multi-Institutional Clinicopathological Study." Pathology. 2021;53(2):214-219. doi:10.1016/j.pathol.2020.07.005

41. Higuchi TT, Granberg CF, Fox JA, Husmann DA. "Augmentation Cystoplasty and Risk of Neoplasia: Fact, Fiction and Controversy." J Urol. 2010;184(6):2492-2496. doi:10.1016/j.juro.2010.08.038

42. Higuchi TT, Fox JA, Husmann DA. "Annual Endoscopy and Urine Cytology for the Surveillance of Bladder Tumors After Enterocystoplasty for Congenital Bladder Anomalies." J Urol. 2011;186(5):1791-1795. doi:10.1016/j.juro.2011.07.028

43. Soergel TM, Cain MP, Misseri R, et al. "Transitional Cell Carcinoma of the Bladder Following Augmentation Cystoplasty for the Neuropathic Bladder." J Urol. 2004;172(4 Pt 2):1649-1652. doi:10.1097/01.ju.0000140194.87974.56

44. Ceyhan E, Mammadov E, Onder SC, Dogan HS, Tekgul S. "FISH: A Promising Screening Tool for Malignancy After Augmentation Cystoplasty?" J Pediatr Surg. 2024;59(4):725-730. doi:10.1016/j.jpedsurg.2023.11.006

45. Stohr BA, Chan E, Anderson JA, et al. "Molecular Characterization of Adenocarcinomas Arising in the Urinary Bladder Following Augmentation Cystoplasty: A Multi-Institutional Study." Hum Pathol. 2022;129:98-102. doi:10.1016/j.humpath.2022.09.003

46. Chan R, Scovell J, Jeng Z, et al. "The Fate of Transitional Urology Patients Referred to a Tertiary Transitional Care Center." Urology. 2014;84(6):1544-1548. doi:10.1016/j.urology.2014.08.022

47. Higuchi T, Holmdahl G, Kaefer M, et al. "International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence." Urology. 2016;94:288-310. doi:10.1016/j.urology.2016.03.019