Senior Vs. Junior Urology Trainees: Factors Associated with Burnout

INTRODUCTION AND OBJECTIVE: Burnout is one of the many challenges physicians may face in their careers. While there are studies focusing on burnout among surgical specialties, there are limited studies focusing on burn out at different levels of training. The aim of this study is to measure and compare rates of burnout between junior and senior trainees in urological surgery as well as to identify changes in training that could be made to improve work-life balance. METHOD(S): To assess professional burnout, respondents completed the 22-item Maslach Burnout Inventory Human Services Survey as part of the 2019 AUA census. Respondents were categorized into junior trainees (PGY1, PGY2, PGY3) and senior trainees (PGY4, PGY5, and fellow). RESULT(S): A total of 512 respondents were included. Senior trainees represented 57% while junior trainees represented 43% of the total cohort. The prevalence of burnout (p=0.005) and high levels of depersonalization (p=0.018) were 50% in junior trainees and 38% in senior trainees. High levels of emotional exhaustion were 9% for junior and 5% for senior trainees (p=0.053) (Table 1). The top changes to improve work life balance for urology trainees were access to meal plans, on-call rooms, and time to attend health appointments (Figure 1). CONCLUSION(S): Juniors experience higher levels of burnout, depersonalization, and emotional exhaustion when compared to seniors. Providing meal plans, on-call quarters, and time to attend health appointments are the top changes to improve work-life balance among urology trainees. These changes may have a dramatic impact on the well-being of our trainees, especially in this post-COVID era. (Figure Presented).

Surgery for urologic cancers after SARS-CoV-2 infection: Adverse outcomes and optimal delay

Background: Perioperative SARS-CoV-2 infection has been associated with increased adverse outcomes. Research conducted early in the COVID-19 pandemic suggested an 8 week delay after SARSCoV-2 infection prior to undergoing surgery. The aim of this study is to determine if prior COVID-19 infection is an independent risk factor for adverse outcomes following surgery for urologic cancers. A secondary objective was to determine the optimal duration to delay surgery, specifically cystectomy, prostatectomy, or nephrectomy, after COVID-19 infection. Method(s): Data from the National COVID Cohort Collaborative (N3C) data enclave was used to conduct this retrospective cross-sectional study. Patients with cancer diagnoses that underwent surgery for urologic cancers after January 2020 were included in the analyses. Urologic surgeries were queried using standard SNOMED concepts corresponding to cystectomy, nephrectomy, and prostatectomy. Patients were assessed for adverse postoperative events that were defined using standard SNOMED clinical concepts. COVID-19 positive patients were identified via the N3C Knowledge Store using positive lab measurement or a positive SARS-CoV-2 diagnosis. Analyses were conducted in the N3C data enclave. Result(s): The study cohort included 38,974 total patients with 15,216, 14,778, and 8,980, undergoing cystectomy, prostatectomy, and nephrectomy, respectively. 2,807 had a history of COVID-19 infection greater than 20 days prior to surgery. Prior history of COVID-19 was independently associated with adverse outcomes for cystectomy (OR 1.21 [1.03-1.43], p<0.05) and nephrectomy (OR 1.27 [1.06-1.52], p<0.05), but not prostatectomy (OR 1.14 [0.95-1.36]). Multivariable regression assessing time to surgery and risk for any adverse events, did not reveal significant benefit to waiting greater than 20 days after COVID-19 infection to operate. Conclusion(s): Patients with known prior COVID-19 infection who underwent surgical treatment of urologic cancers experienced increased risk of adverse surgical outcomes. Among this group, those who delayed surgery greater than 20 days after infection did not demonstrate decreased risk of these negative outcomes across the procedures studied. Optimal surgical delay in the treatment of urologic cancers after COVID-19 infection does not appear to be greater than 20 days.

Evaluation of Augmented Reality Technology in Global Urologic Surgery

Introduction &Objective: Surgical missions are still largely on pause due to COVID-19, leading to missed opportunities for skill sharing between high-income and middle to low-income countries. New commercially available augmented reality (AR) technology facilitates surgical training, allowing mentors in one country to virtually train and skill-share with a mentee in another country during surgical cases in real-time. We hypothesize that AR technology is an effective live surgical training and mentorship modality. Method(s): To evaluate perceived effectiveness of AR technology in global urologic surgery training, surgeon mentors in the USA and UK worked with mentees in Benin performing surgical cases using the Proximie AR system. Proximie includes audiovisual capabilities allowing a mentor in any location to provide a mentee with real-time guidance during the procedure. Following each case, mentor and mentee individually completed a questionnaire assessing the technology. Result(s): Trainers reported AR technology as easy to set-up and use in 73.3% of cases while the trainee reported easy set-up and use in 100% of cases. The visual quality was acceptable to trainers in 60% of cases and "looks like I'm there" in 40%. Visual input/ability to draw on screen had high impact in 80% of cases, with trainers rating the ability to provide anatomical guidance as invaluable or significant in 93.4% of cases. Audio and anatomical guidance had a significant impact for the trainee in 100% of cases. The quality of virtual training v. in-person training was equivalent in 100% of cases for the trainee while trainers found virtual training inferior in 66.7% of cases and equivalent in only 6.7% of cases. Difficulty connecting occurred often in only 1% of cases for trainers but in 12.5% of cases for the trainee. Trainers reported delay or time lag while using the technology in 40% of cases, with lag being problematic in 12.5% of cases. In contrast, the trainee reported rarely experiencing delay or time lag while using the technology in 100% of cases. Conclusion(s): AR technology is useful in facilitating real-time surgical mentorship during the COVID-19 pandemic. The Proximie technology provides visualization that is acceptable and audiovisual capabilities that have significant positive impact on successful case completion. Though AR technology presents its own set of challenges such as difficulty in connecting virtually between trainer and trainee as well as delay or time lag during surgical cases, AR technology may prove a welcome alternative when in-person training is unavailable or limited.

IMPACT OF SARS-COV-2 PANDEMIC ON THE DIAGNOSIS AND SURGICAL INTERVENTION OF COMMON UROLOGICAL CONDITIONS: RESULTS FROM A MULTI-INSTITUTIONAL DATABASE FROM THE UNITED STATES

INTRODUCTION AND OBJECTIVE: The SARS-CoV-2 (COVID) pandemic threatened access to healthcare, raising concerns that patients were going underdiagnosed and undertreated. The aim of our study was to understand the impact of the COVID pandemic on diagnosis and surgical management of common urological conditions. METHODS: Using a large multi-center electronic health record network (TRINETx) consisting of 46 healthcare organizations, we conducted an epidemiological study investigating the number of patients newly diagnosed with common urological conditions and those undergoing urologic surgeries at yearly intervals from March 1st, 2016 to March 1st, 2021. Relevant international classification of diseases (ICD) codes used to identify urologic conditions are elaborated on in Table 1. Current procedural terminology (CPT) codes used to identify surgeries are detailed in Figure 1. We then determined the percentage of newly diagnosed patients who underwent surgery for each specific year. RESULTS: We saw a decrease in number of all urologic surgeries being performed during the initial year of the pandemic (Figure 1). From March 2020-2021, there was a >20% decrease in surgical case load for benign prostatic hyperplasia procedures (-29.5%), prostate biopsies (-30.1%), incontinence procedures (-33.6%), and vasectomies (-22.8%), compared to the preceding year. Radical cystectomies and orchiectomies saw the lowest decrease, -5.9% and -8.6%, respectively. A similar trend was seen in the number of individuals newly diagnosed with urologic conditions and percentage of patients undergoing surgical intervention. The lowest drops were seen with ureteral stent placements (-5.0%) and prostate biopsies (-3.1%). CONCLUSIONS: The number of people receiving urologic diagnoses and surgical case load for urologic procedures significantly reduced during the first year of the COVID pandemic. Providers should be aware of this healthcare disparity, and greater efforts made to identify these missed patients moving forward.

EVALUATION OF AUGMENTED REALITY TECHNOLOGY IN GLOBAL UROLOGIC SURGERY

INTRODUCTION AND OBJECTIVE: Surgical missions are still largely on pause due to COVID-19, leading to missed opportunities for skill sharing between high-income and middle to low-income countries. New commercially available augmented reality (AR) technology facilitates surgical training, allowing mentors in one country to virtually train and skill-share with a mentee in another country during surgical cases in real-time. We hypothesize that AR technology is an effective live surgical training and mentorship modality. METHODS: To evaluate perceived effectiveness of AR technology in global urologic surgery training, surgeon mentors in the USA and UK worked with mentees in Benin performing surgical cases using the Proximie AR system. Proximie includes audiovisual capabilities allowing a mentor in any location to provide a mentee with real-time guidance during the procedure. Following each case, mentor and mentee individually completed a questionnaire assessing the technology. RESULTS: Trainers reported AR technology as easy to set-up and use in 73.3% of cases while the trainee reported easy set-up and use in 100% of cases. The visual quality was acceptable to trainers in 60% of cases and “looks like I'm there” in 40%. Visual input/ability to draw on screen had high impact in 80% of cases, with trainers rating the ability to provide anatomical guidance as invaluable or significant in 93.4% of cases. Audio and anatomical guidance had a significant impact for the trainee in 100% of cases. The quality of virtual training v. in-person training was equivalent in 100% of cases for the trainee while trainers found virtual training inferior in 66.7% of cases and equivalent in only 6.7% of cases. Difficulty connecting occurred often in only 1% of cases for trainers but in 12.5% of cases for the trainee. Trainers reported delay or time lag while using the technology in 40% of cases, with lag being problematic in 12.5% of cases. In contrast, the trainee reported rarely experiencing delay or time lag while using the technology in 100% of cases. CONCLUSIONS: AR technology is useful in facilitating realtime surgical mentorship during the COVID-19 pandemic. The Proximie technology provides visualization that is acceptable and audiovisual capabilities that have significant positive impact on successful case completion. Though AR technology presents its own set of challenges such as difficulty in connecting virtually between trainer and trainee as well as delay or time lag during surgical cases, AR technology may prove a welcome alternative when in-person training is unavailable or limited.

The impact of the Covid-19 pandemic on the short and mid-term urological emergencies and the emergency department

Dynamic changes are observed in the delivery of health care services due to the COVID-19 Pandemic. Its effect in the short term is a dramatic decrease in service, however, its effect in the medium and long term is unknown. In this study, we aimed to investigate the effects of the COVID-19 pandemic on emergency department and emergency urological surgery in the short and medium term during the 8-month period, and the reasons for possible changes. Emergency department operations, urology operations and emergency surgical procedures between April and November were compared as the 2020 pandemic period and the 2019 non-pandemic period. The relevant information was obtained from the hospital management information system. Descriptive analysis and statistical methods comparing the two periods were used. In the early stages of the pandemic, significant decreases were observed in both urology procedures and emergency department operations. In the medium period, while emergency department operations and urology consultations returned to the non-pandemic periods, there was no such a change in in emergency urological surgeries. In the medium-term effects of the pandemic, emergency department operations returned to the non-pandemic periods due to reasons such as patients' abuse of emergency departments in line with their requests for rapid diagnosis and treatment. In accordance with the changing nature of the pandemic, it is necessary to make different scheduling for emergency department operations and emergency surgeries.

The impact of COVID-19 on surgical care delivery for patients with urinary stones

Introduction & Objective: During the COVID-19 pandemic, limits on elective surgical care were instituted by hospitals to preserve resources. Additionally, patients' desire to limit health care contact may impact surgical decision making.We aimed to understand how institutional pressures and patient preference affected the delivery, choice and outcome of ambulatory surgical care for urinary stone disease during the COVID-19 pandemic. Methods: Reducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) that maintains a prospective clinical registry of ureteroscopy (URS) and shockwave lithotripsy (SWL) cases. Using this registry, we categorized all cases by time frame, defining July 1st - December 31st 2019 as preCOVID (PC), March 16th - June 15th 2020 as duringCOVID (DC) and June 16th - September 15th 2020 as afterCOVID (AC). Patients in each cohort were characterized across a range of sociodemographic and clinical factors. We assessed changes in procedure choice (URS vs SWL), procedure acuity (elective vs emergent), and outcomes (ED visit and hospitalization within 30 days of surgery). Results: 6375 cases were identified, 4513 URS and 1862 SWL. PC consisted of 3310 cases (2238 URS and 1072 SWL), DC consisted of 1141 cases (888 URS and 253 SWL) and AC consisted of 1924 cases (1387 URS and 537 SWL). A higher proportion of URS cases were performed DC compared to PC and AC (77.8% vs 67.6% vs 72.1%, p < 0.001, respectively). A higher percentage of emergent cases in DC compared to PC and AC (21.8% vs 13.7% vs 15.3%, p < 0.001, respectively). Significantly more cases in DC compared to PC and AC were prestented, had positive UA/urine culture, ureteral stones, had hydronephrosis, were stented and had longer stent dwell time. ED visits and unplanned hospitalizations were not significantly different. Conclusions: The COVID-19 pandemic resulted in a lower overall stone treatment rates and higher proportions of URS compared to SWL. Significantly more emergent cases for ureteral stones with positive UA/urine cultures and evidence of obstruction were performed duringCOVID with higher stent placement rates and longer stent dwell times. These data pointing towards preference for higher intensity or acuity cases without differences in unplanned healthcare encounters. (Table Presented).

Influence of COVID-19 pandemic on stress levels of urologic patients.

INTRODUCTION: Several studies have shown the consequences of COVID-19 pandemic on perceived stress of different populations, but none of them analyzed urological patients who underwent elective surgery. METHODS: We enrolled prospectively patients who underwent elective surgery between March and October 2020. A survey on COVID-19 and the 4-item Perceived Stress Scale (PPS-4) questionnaire were administered at hospital admission. Demographic and medical history data were also collected. Uni- and multivariate analyses were performed to identify independent predictors of higher PSS-4 values (≥7). RESULTS: A total of 200 patients were enrolled. Mean PSS-4 value resulted 6.04. Patients with PSS-4 value ≥7 resulted 43.5% (87/200). In multivariate analysis, PSS-4 value ≥7 was independently associated (p < 0.05) with female gender (OR 6.42), oncological disease (OR 2.87), high (>5 in a range between 0 and 10) fear of intrahospital transmission of SARS-CoV-2 infection (OR 4.75), history of bladder instillation (OR 0.26), and current smokers (OR 0.27). CONCLUSION: High PSS-4 values at hospital admission in urologic surgical patients are positively correlated with female gender, fear of intrahospital transmission of SARS-CoV-2 infection, and oncological disease. PSS-4 questionnaire could be useful to select patients for whom a preadmission counselling is necessary to improve the management of their high stress level.

Design of an assistance protocol for the restart of scheduled urologic surgery in a COVID-19 epidemic period. / Diseño de un protocolo asistencial para el reinicio de la cirugía urológica programada en periodo de epidemia COVID-19.

OBJECTIVE: Design a care protocol to restart scheduled surgical activity in a Urology service of a third level hospital in the Community of Madrid, in a safe way for our patients and professionals in the context of the SARS-CoV-2 coronavirus epidemic. MATERIAL AND METHODS: A multidisciplinary group reviewed the different recommendations of the literature, national and international health organizations and scientific societies, as well as their application to our environment. Once scheduled surgery has restarted, the patients undergoing surgery for complications related to COVID-19 are being followed up. RESULTS: Since the resumption of surgical activity, 19 patients have been scheduled, of which 2 have been suspended for presenting COVID-19, one diagnosed by positive PCR for SARS-CoV-2, and another by laboratory and imaging findings compatible with this infection. With a median follow-up of 10 days (4-14 days), no complications related to COVID-19 were detected. CONCLUSIONS: Preliminary results indicate that the protocol designed to ensure the correct application of preventive measures against the transmission of coronavirus infection is being safe and effective.