Practice Trends in OnabotulinumtoxinA and Augmentation Cystoplasty: Implications for Adult and Pediatric Urology

OnabotulinumtoxinA (OnabotA) injections and augmentation cystoplasty (AC) are established interventions for refractory bladder dysfunction in adults and children. The impact of growing OnabotA use in neurogenic populations on AC utilization remains unclear. Characterizing contemporary practice patterns is essential to inform training, guideline development, and health care delivery.

We analyzed national procedural data from 2002 to 2024 to assess OnabotA and AC utilization among adult and pediatric urologists. Providers were categorized as performing AC only, OnabotA only, or both. Volume, demographic, and practice characteristics were compared across cohorts.

Among 3711 urologists performing 20,883 procedures, 38.4% performed OnabotA only, 4.6% AC only, and 6.8% both. Pediatric urologists (8.8% of the cohort) performed 66.1% of AC cases and 3.2% of OnabotA cases. AC-only pediatric urologists were older and more likely male than OnabotA-only providers. Among adult urologists, OnabotA use increased sharply after US Food and Drug Administration approval in 2011, surpassing AC volumes by 2013 and reaching a 360-fold higher rate by 2015. OnabotA-only providers were predominantly general urologists in private practice, whereas AC was mainly performed by reconstructive specialists. Pediatric urologists demonstrated rapid adoption of OnabotA, with procedure proportions approximating AC by 2022.

Since its approval for intradetrusor use, OnabotA has been increasingly adopted by pediatric and adult urologists, although with different trends suggesting unique applications of OnabotA. Among adult urologists, AC volumes declined but persisted, underscoring its continued role as a niche procedure for complex or refractory cases. OnabotA may complement, rather than replace, AC in the management of refractory bladder dysfunction.