Christopher P. Smith, MD, MBA, MSS, presented “BoNT-A: Now and Beyond: 2025” during the 29th Annual Innovations in Urologic Practice on September 19th, 2025, in Santa Fe, New Mexico.
How to cite: Smith, Christopher P. “BoNT-A: Now and Beyond: 2025.” September 19th, 2025. Accessed Dec 2025. https://grandroundsinurology.com/bont-a-now-and-beyond-2025/
BoNT-A: Now and Beyond: 2025 – Summary
Christopher P. Smith, MD, MBA, MSS, Associate Professor of Urology, Baylor College of Medicine, Houston, Texas, discusses the evolution of botulinum toxin type A (BoNT-A) from laboratory experimentation to clinical application in urology. He explains that despite its potency as a neurotoxin, BoNT-A is highly therapeutic in small, localized doses. His initial research at the University of Pittsburgh demonstrated that BoNT-A inhibits the release of acetylcholine and adenosine triphosphate (ATP) from parasympathetic nerves in rat bladders, providing selective suppression of hyperactivity without impairing normal detrusor function.
Following these early studies, clinical trials led to US Food and Drug Administration (FDA) approval for neurogenic detrusor overactivity in 2011 and idiopathic overactive bladder in 2013. Pooled analyses confirmed meaningful reductions in urgency incontinence episodes, with similar efficacy across genders. Dr. Smith notes that definitions of retention remain inconsistent across studies, which complicates their interpretation.
He describes his modified 10-injection trigonal and bladder-base template, which reduces patient discomfort and retention risk while maintaining efficacy. Deep detrusor injections appear to have greater durability than suburothelial techniques, although suburothelial placement may reduce the risk of catheterization.
Dr. Smith also explores the sensory effects of BoNT-A, demonstrating evidence of reduced ATP and neuropeptide release from the urothelium and afferent nerves, which suggests a potential benefit in pain modulation. He shares his preferred dosing strategies—typically 100 units for non-catheterizing patients and up to 400 units in select cases—to balance efficacy, risk of retention, and patient comfort.
About The 29th Annual Innovations in Urologic Practice:
Presented by co-chairs Mohit Khera, MD, MBA, MPH, and Michael Coburn, MD, FACS, the Innovations in Urologic Practice conference provides a detailed review and commentary on multiple genitourinary and urologic diseases. Among the featured oncological topics are bladder cancer and immunotherapies, as well as upper tract cancer management, prostate cancer, including state-of-the-art imaging, focal therapy, and MRI. Experts also discuss new tools and techniques for nephrectomy and treating advanced renal cell carcinoma. In terms of general urological approaches, the conference also includes pelvic reconstruction and trauma, men’s health topics like male infertility and sexual dysfunction, and ways to diagnose and treat infections in the urology patient. Dr. Smith presented this talk at the 2025 conference.
For further educational activities from this conference, visit our collection page.
ABOUT THE AUTHOR
Christopher P. Smith, MD, MBA, MSS, is an associate professor and board-certified urologist specializing in male and female urinary incontinence and voiding dysfunction. Dr. Smith is also a Colonel in the United States Army Reserve Corps and has been deployed three times in support of Operation Enduring Freedom (OEF). Dr. Smith attended Northwestern University Medical School in Chicago and completed his residency training in urology at Baylor College of Medicine. He completed his fellowship training under a National Institutes of Health (NIH) K12 Scholarship in Neurology and Female Urology at the University of Pittsburgh School of Medicine in Pennsylvania. He earned his MBA at the Katz School of Business, University of Pittsburgh, and his Master of Strategic Studies from the U.S. Army War College in Carlisle, Pennsylvania.
Dr. Smith has published numerous articles in scientific journals, including over 70 peer-reviewed papers and many invited articles to other publications. An active academician and speaker, he has presented many papers at scientific meetings and has served as guest lecturer across the country. Dr. Smith is an international expert on the basic and clinical aspects of botulinum toxin use within urology. He has used botulinum toxin clinically for over a decade. Dr. Smith is a principal investigator on several clinical trials examining the effects of botulinum toxin to treat patients with overactive bladder and benign prostatic hyperplasia (BPH). In 2012, Dr. Smith was awarded a Department of Defense grant to compare the efficacies of onabotulinumtoxinA vs. oxybutynin in spinal-cord injury patients with neurogenic detrusor overactivity and a VA Merit Grant to compare the efficacy of onabotulinumtoxinA vs. tamsulosin in men with BPH and lower urinary tract symptoms.
Dr. Smith was awarded the Paul Zimskind Award in 2006 by the Society for Urodynamics and Female Urology for continuing excellence and leadership in the field of voiding dysfunction. He was awarded a three-year Career Development Award by the Department of Veterans Affairs to study the role of spinal purinergic pathways in the development of bladder overactivity. In addition, he has been honored with the Astellas Rising Star in Urology Award by the American Urological Association Foundation for three years to support his career development research. Dr. Smith received 2nd prize in the prestigious Jack Lapides Essay Contest for a research paper in 2008 investigating the effects of botulinum toxin A in spinal cord injured bladders, as well as the Apple Award from the American Spinal Injury Association. He has also been listed in Castle Connolly’s America’s Top Doctors.
