Development and Validation of a Mixed-Reality Simulator for Reducing Biopsy Core Deviation During Simulated Freehand Systematic Prostate Biopsy.

INTRODUCTION: We describe the development and validation of a mixed-reality prostate biopsy (PBx) simulator with built-in guidance aids and real-time 3-dimensional visualization. METHODS: We evaluated our simulator during one-on-one training sessions with urology residents and attendings from 2018 to 2022. Participants performed freehand, side-fire, double-sextant transrectal ultrasound-guided systematic prostate biopsy (sPBx). After a baseline assessment (first set of 12 biopsy cores), participants trained for 25 minutes with visualization and cognitive aids activated. Training was followed by an exit set of 12 biopsy cores without visualization or cognitive aids and afterward, subjective assessment by trainees of the simulator. Deviation is the shortest distance of the center of a core from its intended template location. RESULTS: Baseline deviations (mean ± SD) for residents (n = 24) and attendings (n = 4) were 13.4 ± 8.9 mm and 8.5 ± 3.6 mm ( P < 0.001), respectively. Posttraining deviations were 8.7 ± 6.6 mm and 7.6 ± 3.7 mm ( P = 0.271), respectively. Deviations between baseline and exit were decreased significantly for residents ( P < 0.001) but not for attendings ( P = 0.093). Overall feedback from participants was positive. Confidence in performing a PBx increased in novices after training ( P = 0.011) and did not change among attendings ( P = 0.180). CONCLUSIONS: A new PBx simulator can quantify and improve accuracy during simulated freehand sPBx while providing visualization and graphical feedback. Improved simulated sPBx accuracy could lead to more even distribution of biopsy cores within the prostate when performed in clinical settings, possibly reducing the high risk of missing an existing lesion and thus decreasing the time to initiating treatment, if indicated.

An alternative approach of cystoscopy-guided removal of a recalcitrant foley catheter.

Foley balloon malfunction can result in recalcitrant catheters. Management approaches for troubleshooting this rare occurrence have been described in the literature, including the more invasive methods such as the use of cystoscopy for direct visualization. We describe a case of our endourologic management of a retained 14F temperature-probe foley catheter in a fifty-nine-year-old female patient.

Understanding Patient Expectations and Determinants of Satisfaction in an Outpatient Urology Clinic at an Academic Medical Center.

OBJECTIVE: To examine and better understand expectations and facilitators of satisfaction amongst patients presenting to an ambulatory urology clinic at an academic medical center. METHODS: Patients completed an anonymous survey regarding expectations for their clinic visit. Patients were included in the investigation if they were aged 18-89 years and had the ability to complete informed consent. Chi-square analysis was then used to analyze the collected data. RESULTS: A total of five hundred patients were enrolled in the study. Patients were predominantly white males and were older than 60 years of age. Most patients had at least a college education and drew an annual household income between $40,000-$99,999. Most enrollees were return patients (74.8%). Most expected to be seen within 3-7 days of referral and expected 16-30 minutes with their provider. Patients noted they would not be equally satisfied seeing a physician vs advanced practice provider on their initial visit but would on a return visit. About half (52%) of the cohort stated they would be dissatisfied with their clinic experience if their expectations were not met. Significance was found between variables including age, race, gender and type of visit and their survey responses. CONCLUSION: Patient satisfaction remains an important measure for the quality and safety of patient care. This investigation highlighted patient prioritization of time to be seen after referral and the provider that cares for them at both initial and follow-up visits. Future research is needed to enhance stakeholder understanding of precisely how expectations impact overall satisfaction.

Attitude is everything: keep probe pitch neutral during side-fire prostate biopsy. A simulator study.

OBJECTIVES: To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) false-negatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. PARTICIPANTS AND METHODS: Using a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirty-four trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm. RESULTS: All results are reported as mean ± sd. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 ± 4.1° and 8.0 ± 2.7 mm, respectively, and after mastering the technique decreased to 4.5 ± 2.7° (P = 0.001) and 4.5 ± 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1° increase in mean absolute pitch. Participants achieved mastery after practising 3.9 ± 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 ± 102 s) and mastery (283 ± 101 s; P = 0.39). CONCLUSION: A pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.

Patient Perceptions of Chaperones during Intimate Examinations and Procedures in Urology Clinic.

INTRODUCTION: We surveyed patients on their expectations and preferences regarding chaperones during intimate examinations and procedures in urology clinic. METHODS: Patients identified in the outpatient urology clinic were queried for demographics, expectations and preferences regarding chaperones through a 16-item survey. RESULTS: We collected data from 200 patients (52.5% male, 47.5% female), average age 60.5 years (SD ± 15.5). Most patients were Caucasian (84.5%), completed some college (65.5%) and were married (52.0%). Most had a prior genitourinary procedure (men 74.7%, women 62.4%), during which 21.5% of men vs 60.7% of women had chaperones present. Most patients did not care if they had a chaperone (men 53.3%, women 54.7%). Only 11.5% of patients preferred a chaperone. Of that minority there was a higher percentage of women who preferred a chaperone compared to men (men 3.8%, women 20%). The majority of patients did not care about the gender of the chaperone but cited comfort level with the provider (men 50.0%, women 54.9%) and invasiveness of procedure or examination (men 36.4%, women 35.4%) as most important. The majority of patients (men 84.8%, women 88.4%) felt that they should have the right to refuse a chaperone. CONCLUSIONS: A minority of patients preferred to have a chaperone during an intimate examination or procedure in urology clinic. Patients prioritized comfort level with the provider, which trumped gender of provider, invasiveness of examination and identity of the chaperone. The use of chaperones during intimate examinations and procedures is routine at many institutions. In an era of patient centered care it is crucial to understand patient preferences and expectations.

Career Expectations and Preferences of Urology Residency Applicants.

OBJECTIVE: To survey the characteristics, career goals, and practice preferences of current urology applicants. METHODS: An anonymous survey was emailed to applicants pursuing a residency position at the University of Florida for the 2017-2018 academic year Urology Match. The survey included questions on demographics, motivating factors to pursue urology, plans for fellowship training, and anticipated and desired practice patterns. RESULTS: A total of 151 of 295 applicants completed the survey, mean age 26.9± SD 2.3. Males had a higher interest in academics/research, cancer, men's health, and minimally invasive surgery technology. Females had a higher interest in public health, surgery, and mixture of surgical and medical management. A total of 64.1% planned on completing a fellowship. Males had a higher interest in urologic oncology and endourology. Females had a higher interest in female pelvic medicine and reconstructive surgery, andrology and sexual medicine, and pediatric urology. A total of 76.9% anticipated having an academic affiliation, 68.9% working in an urban setting, and 98% working full-time, with no difference based on gender. For desired quality of life after residency, maximum number of hours considered acceptable was 51-60 (36.4%) and 61-70 (35.1%). Regarding an acceptable call schedule, most considered 2-4 nights per month reasonable. Most felt an acceptable starting salary was $250,000-$400,000 and $200,001-$350,000 for private practice and academic urology, respectively. CONCLUSION: Current urology applicants desire to work in academics, urban settings, and pursue subspecialty fellowship training. What they consider acceptable work hours, call schedule, and financial compensation appear compatible with the current practice of urology.

Gender and Subspecialty of Urology Faculty in Department-based Leadership Roles.

OBJECTIVE: To characterize the current gender and subspecialty of those holding academic departmental administrative and educational leadership roles in urology. METHODS: We conducted a cross-sectional observational study of U.S. Urology Residency Programs in 2016-2017. Inclusion criteria were participation in the Urology Residency Match Program and having a department of urology website. From June 1, 2016 to August 20, 2016, each department's website was queried. If information was missing or unclear, we reviewed faculty biographies and contacted residency program coordinators. RESULTS: We queried 124 urology residency programs. For administrative leadership roles, women comprised 3.3% of chairs, 4.5% of vice chairs, and 7.9% of division directors. For educational leadership roles, women comprised 9.4% of fellowship directors, 8.1% of residency directors, and 27.4% of medical student clerkship directors. The most common subspecialties for chairs included oncology (49.2%), endourology (16.4%), and female urology (7.4%). Among division directors, female urology had the highest representation of women (27.8%) followed by pediatric urology (9.8%), reconstruction (5%), endourology (4.3%), and andrology (4%). CONCLUSION: Overall, women are disproportionately underrepresented when it comes to educational and administrative positions of urology departmental leadership. There is also a wide yet narrowing gender gap as more women are pursuing careers in this field. Given this upward trend we may see more women in positions of leadership over time. Future efforts should be made to help promote the advancement of women to positions of leadership.

Hydronephrosis Presenting 6 Months After Sacral Colpopexy: Case Report and Literature Review.

OBJECTIVES: The aim of this study was to describe a case of uterovaginal prolapse managed with robotic-assisted sacral colpopexy complicated by severe right-sided hydronephrosis despite normal intraoperative cystoscopy. METHODS: A 68-year-old woman presented with a worsening vaginal bulge over the past 2 years. Tricompartment stage 2 uterovaginal prolapse, with dominant cystocele and skin erosion at the posterior fourchette from prolapse friction, was identified on physical examination, and the patient underwent pelvic reconstructive surgery, including sacral colpopexy. RESULTS: The patient was discharged on postoperative day 4 after being treated for a urinary tract infection. At her 6-week postoperative visit, the patient demonstrated normal vaginal support. She presented 6 months postoperatively with right-sided hydronephrosis with an almost imperceptible stricture where the right iliac vessels cross the pelvic brim, demonstrating a delayed manifestation of ureteral injury. She underwent open ureteroscopy, ureteroneocystostomy with vesicopsoas hitch, and ureteral stent placement. Ureteroscopy demonstrated a very mild narrowed caliber of the ureter just above the sacroiliac joint without overt obstruction. Follow-up intravenous pyelogram demonstrated no evidence of damage or obstruction. At nearly 1-year follow-up, the patient remained asymptomatic and had normal renal function. CONCLUSION: This case demonstrates the challenges of an uncommon, but highly morbid, complication of pelvic reconstructive surgery. Even when adequate visualization of the ureters and delicate ureteral dissection is achieved throughout surgery, occult injuries can still occur. Surgeons should maintain a high index of suspicion of ureteral injury when evaluating patients for late presentations of postoperative complications.

Evaluating and managing urinary incontinence after prostatectomy: beyond pads and diapers.

Men who become persistently incontinent after undergoing prostatectomy have a variety of options for regaining control, ranging from behavioral changes to surgery. To determine the best therapy, one should define the problem with a thorough urologic evaluation.