Authorship in Urology: A Gender Reveal.

OBJECTIVE: To evaluate female author representation in urologic literature as compared to the proportion of female practicing urologists. METHODS: A cross-sectional study was designed to analyze trends in women authorship of urology publications in 2019 as compared to AUA 2019 census data. The 5 highest impact urologic journals in 2019 were identified using the publicly available SCImago Journal Rank (SJR) indices. Author genders and study categorization were independently determined by 2 authors. Chi-squared test was used for statistical analyses. RESULTS: The 5 highest impact urologic journals in 2019 as per SJR were European Urology, Journal of Urology, British Journal of Urology International, Prostate Cancer and Prostatic Diseases, and Nature Reviews Urology. A total of 501 publications were included for analysis. Women comprised 22.1% of first authors and 14.6% of senior authors. The proportion of publications authored by women was significantly higher than would be expected based on population proportions from the AUA 2019 census data for women as both first (P < .0001) and senior author (P =.0005). Similarly, women authorship was significantly higher than expected for basic science (P < .0001), clinical medicine (P <.0001), economics/practice management (P =.0002), editorial (P =.0027), and review/meta-analysis (P <.0001) publications. CONCLUSION: The present study demonstrates that women contribute to the urologic literature significantly more than would be expected based on the proportion of practicing female urologists. However, with the persistence of gender gap in academic medicine promotions, further research into contributing factors and strategies for improvement are needed to promote greater women representation in academia.

Urological Education in United States Medical Schools: Where Are We Now and How Can We Do Better?

INTRODUCTION: While urological complaints increase in aging populations and conditions commonly require management by multiple physician specialty types, exposure to formal urological education in United States medical schools is limited and has been decreasing over time. We aim to update the current status of urological education in the United States curriculum and delve further into the subject matter being taught and the type and timing of this education. METHODS: An 11-question survey was developed to describe the current status of urological education. The survey was distributed using Survey Monkey to the American Urological Association's medical student listserv in November 2021. Descriptive statistics were used to summarize survey findings. RESULTS: Of 879 invitations sent, 173 responded (20%). Most (112/173, 65%) of respondents were in their fourth year. Only 4 (2%) reported that their school had a required clinical urology rotation. Kidney stones (98%) and urinary tract infections (100%) were the most frequent topics taught. The least exposure included infertility (20%), urological emergencies (19%), bladder drainage (17%), and erectile dysfunction (13%). Videos and case vignettes were the preferred learning modalities and the majority (84%) of respondents were familiar with the American Urological Association's medical student curriculum material. CONCLUSIONS: The majority of United States medical schools do not have a required clinical urology rotation and some core urological topics are not taught at all. Future incorporation of urological educational material through video and case vignette learning may be the best opportunity to provide exposure to clinical topics that will commonly be encountered regardless of chosen medical discipline.

Feasibility and Utility of Mobile Applications for the Evaluation of Urology Residents' Surgical Competence.

OBJECTIVE: To provide real-time assessment and feedback on the competency of urology residents' surgical skill via mobile applications and examine their feasibility and utility. MATERIALS AND METHODS: Two mobile application-based systems (SIMPL and myTIPreport) were sequentially implemented for the case-by-case assessment of residents' performance of surgical skills at a single institution. Data was collected regarding residents' perception of their feedback pre- and post-implementation of the applications. Faculty were surveyed after their implementation to determine their feasibility and utility. RESULTS: 297 individual evaluations were completed with SIMPL and 822 with myTIPreport over four and eleven months respectively. Post-implementation, residents showed significantly improved perceptions regarding the quantity and personalization of surgical skill feedback (P = .043 and .005 respectively). A majority (75%) of the faculty found the mobile applications feasible to use, an improvement compared to prior methods of resident evaluation, and would recommend continued use. CONCLUSION: This study represents the first documented use of real-time surgical competency assessment in urology. The use of mobile applications to evaluate urology residents' surgical competency in clinical practice is both feasible and useful. Their use may allow for more individualized surgical skill teaching during training and for the verification of the surgical skills necessary to practice autonomously.

Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients.

OBJECTIVES: To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. PATIENTS AND METHODS: Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. RESULTS: The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. CONCLUSIONS: Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

Strange Vibes - Novel Presentation of Prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has significant variability in its presentation. In this study, we present 2 novel cases of prostatitis in which "buzz" is described as the primary pain symptom. These cases describe patients with the primary complaint of "cell phone-like buzzing" within the perineum, with accompanying urinary symptoms consistent with prostatitis. CP/CPPS is a multifactorial disease within which psychological, inflammatory, neurologic, and neuromuscular etiologies are at play. As in other disease descriptions, a buzzing sensation represents the interaction of multiple pathways that have significant overlay with CP/CPPS. As such, we believe buzzing might represent a new symptom of CP/CPPS.

Renal cell recurrence for T1 tumors after laparoscopic partial nephrectomy.

OBJECTIVES: There is lack of consensus in the Urology community regarding surveillance after laparoscopic partial nephrectomy (LPN), particularly for patients with stage I tumors. The purpose of this article is to characterize the rate of recurrence after partial nephrectomy in a low risk cohort. METHODS: Data were collected on all laparoscopic partial nephrectomies performed at a single institution from January 2006 through May 2011. Patients without at least 1 year of follow-up information were excluded from examination. Patients were stratified based on the pathologic tumor stage at the time of partial nephrectomy. Patients with stage I (a and b) tumors were then examined for recurrence. RESULTS: A total of 639 patients underwent LPN during the time period. Of this, 360 patients had stage T1 renal cell carcinoma (RCC) (302 with pT1a and 58 with pT1b) and met research criteria. There were 8 recurrences (2.2%) within this cohort ( Table 1 ). All of the tumors were of clear cell histology and none had Furhman grade 1 histology. Only one of these patients had a positive margin at the time of partial nephrectomy and all patients had negative biopsy of the tumor resection bed. A majority of the recurrences occurred locally in the ipsilateral kidney or retroperitoneum. Most of the recurrences occurred within 1-2 years postoperatively. CONCLUSIONS: Approximately 2% of patients who underwent LPN for RCC with resultant low risk, stage I tumor pathology developed metastasis. There were no recurrences in nonclear cell pathologies and no recurrences with Furhman grade 1 or tumors smaller than 3 cm.

Hilar clamping versus off-clamp laparoscopic partial nephrectomy for T1b tumors.

PURPOSE OF REVIEW: An off-clamp, or zero-ischemia, approach to laparoscopic partial nephrectomy has been a proposed means of preserving global renal function by preventing ischemia to normal renal parenchyma. However, for clinical stage T1b tumors this provides a unique challenge as the large size of these tumors further complicates an already difficult procedure. This review provides an overview of outcomes for laparoscopic partial nephrectomies performed with or without hilar clamping for clinical stage T1b tumors. RECENT FINDINGS: There is a paucity of data for laparoscopic partial nephrectomies for this larger tumor size. The feasibility of performing laparoscopic partial nephrectomy for renal tumors 4-7 cm in size has clearly been demonstrated. Not unexpectedly, using an off-clamp technique during laparoscopic partial nephrectomy has variably shown increased intraoperative blood loss when compared to hilar controlled procedures. This does not, however, seem to translate into increased risk of transfusion or loss of visualization leading to compromise in oncologic outcomes. Lastly, some data suggest improved short-term and long-term preservation of renal function as estimated by estimated glomerular filtration rate. SUMMARY: With accumulating data pointing to the long-term health benefits of nephron sparing surgery over radical nephrectomy and its oncologic equivalency confirmed, there is an increased push to perform partial nephrectomy for larger tumors. As demonstrated in the setting of a solitary kidney, every minute of warm ischemia counts and ischemia is an important modifiable variable that impacts renal function. As such, off-clamp dissection has potential advantages. The reviewed data show that foregoing hilar clamping for T1b tumors is not only feasible, but is likely beneficial with respect to renal function and does not appear to carry an increased risk of transfusion despite increased blood loss.

Predictors for negative ureteroscopy in the management of upper urinary tract stone disease.

OBJECTIVE: To identify factors predictive of negative ureteroscopy (URS). Although computed tomography (CT) scans are sensitive in assessing upper tract calculi, there is increased effort to limit CT radiation exposure. On occasion, patients undergo URS and it is discovered that the stone has already passed. METHODS: Retrospective chart review was conducted on all URS cases for renal and ureteral stones performed by a single surgeon from August 2003 to May 2008. Renal units were examined separately and excluded for stone size >10 mm, staged procedures, and previously placed ureteral stents. Negative URS cases were compared with those where stones were identified for differences in stone size, location, presence of preoperative pain, time interval since CT, presence of hydronephrosis, and use of medical expulsive therapy (MET). RESULTS: Two-hundred fifty-six cases were identified. Twenty-five of 256 renal units (9.8%) did not have stones upon direct visualization. Stone size (P < .001) and stone location (P = .043) were significantly associated with outcome on univariate analysis. On multivariate analysis, only stone size was significant (P < .001). CONCLUSION: Negative URS occurred in almost 10% of cases, with reasonable chance of spontaneous stone passage. Our data support smaller stone size and distal location as predictive of negative URS as opposed to preoperative pain, presence of hydronephrosis, and use of MET. Time interval since CT was not predictive. Rate of negative ureteroscopy is not insignificant, thus patients with small, distal stones who elect to undergo URS should be counseled regarding negative URS with an alternative being repeat imaging.

Is a safety wire necessary during routine flexible ureteroscopy?

BACKGROUND AND PURPOSE: The use of flexible ureteroscopy (URS) for nephrolithiasis has been rapidly expanding. Initially, safety guidewires were maintained alongside the ureteroscope during stone manipulation to prevent loss of access and allow stent insertion in the event of perforation. We intend to determine the safety of flexible URS without a separate safety guidewire in a large series of patients. METHODS: A retrospective chart review was performed on all cases of flexible URS with laser lithotripsy performed by a single surgeon from August 2003 to May 2008. Preoperative patient characteristics, radiographic stone sizes, operative findings, and postoperative outcomes were recorded. Patients with renal or ureteropelvic junction (UPJ) stones were isolated for a qualitative data analysis. RESULTS: Flexible URS was performed on 305 kidneys in 246 consecutive patients, of which 59 cases were bilateral. Cases were subdivided into complicated and uncomplicated. Two hundred seventy cases were uncomplicated and performed without a safety guidewire. No intraoperative complications resulted from the lack of a safety guidewire, including no cases of lost access, ureteral perforation/avulsion, or need for percutaneous nephrostomy tube. Thirty-five cases were complicated, necessitating a safety guidewire. Of these, 16 had concomitant obstructing ureteral stones, 5 had encrusted ureteral stents, and 14 had difficult access because of large stone burden or aberrant anatomy. CONCLUSIONS: This study demonstrates that, in a large series of patients, a safety guidewire was not necessary for routine cases of flexible URS with laser lithotripsy on renal or UPJ stones. Particular cases with complicated anatomy, difficult access, concomitant ureteral stones, simultaneous stone basketing, or bulky stone burden still necessitate use of a safety guidewire because of increased risk of adverse outcomes.