The prevalence of impostor phenomenon and its association with burnout amongst urologists.

OBJECTIVES: To characterise the prevalence of impostor phenomenon (IP; tendency for high-achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout. SUBJECTS AND METHODS: A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e-mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America. RESULTS: A total of 614 survey responses were received (response rate 11.0%). In all, 40% (n = 213) of responders reported CIPS scores qualifying as either 'frequent' or 'intense' impostorism (i.e., scores of 61-100). On multivariable analysis, female gender, fewer years in practice (i.e., 0-2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04-1.07; P < 0.001). CONCLUSION: Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers.

Perioperative Outcomes of Vesicovaginal Fistula Repair by Surgical Approach.

IMPORTANCE: Data comparing perioperative outcomes between transvaginal, transabdominal, and laparoscopic/robotic vesicovaginal fistula (VVF) repair are limited but are important for surgical planning and patient counseling. OBJECTIVE: This study aimed to assess perioperative morbidity of VVF repair performed via various approaches. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify women who underwent transvaginal, transabdominal, or laparoscopic/robotic VVF repair from 2009 to 2020. Associations of surgical approach with baseline characteristics, blood transfusion, prolonged hospitalization (>4 days), and 30-day outcomes (any major or minor complication or return to the operating room) were evaluated with χ 2 , Fisher exact, and Kruskal-Wallis tests. Multivariable logistic regression models assessed the adjusted association of approach with 30-day complications and prolonged hospitalization. RESULTS: Overall, 449 women underwent VVF repair, including 252 transvaginal (56.1%), 148 transabdominal (33.0%), and 49 laparoscopic/robotic procedures (10.9%). Abdominal repair was associated with a longer length of hospitalization (median, 3 days vs 1 day transvaginal and laparoscopic/robotic; P < 0.001), higher risk of prolonged length of stay (abdominal, 21.1%; transvaginal, 4.0%; laparoscopic/robotic, 2.0%; P < 0.001), major complications (abdominal, 4.7%; transvaginal, 0.8%; laparoscopic/robotic, 0.0%; P = 0.03), and perioperative transfusion (abdominal, 5.0%; transvaginal, 0.0%; laparoscopic/robotic, 2.1%; P = 0.01). On multivariable analysis, the abdominal approach was independently associated with an increased risk of prolonged hospitalization compared with laparoscopic/robotic (odds ratio, 12.3; 95% confidence interval, 1.63-93.21; P = 0.02) and transvaginal (odds ratio, 6.09; 95% confidence interval, 2.87-12.92; P < 0.001) but not with major/minor complications ( P = 0.76). CONCLUSION: Transvaginal and laparoscopic/robotic approaches to VVF repair are associated with lower rates of prolonged hospitalization, major complications, and readmission compared with a transabdominal approach.

Characterization of Gender Differences in H-index Within Urological Subspecialties.

PURPOSE: Previous work in urology has shown that men have higher h-indices than women. However, the degree to which h-indices vary by gender within urological subspecialties has not been well defined. Herein, we assess gender differences in h-index among different subspecialties. MATERIALS AND METHODS: Demographics were recorded for academic urologists using residency program websites as of July 2021. Scopus was queried to identify h-indices. Gender differences in h-index were estimated from a linear mixed-effects regression model with fixed effects for gender, urological subspecialty, MD/PhD status, years since first publication, interactions of subspecialty with years since first publication, and interactions of subspecialty with gender and random effects for AUA section and institution nested within AUA section. The Holm method was used to adjust for multiplicity (7 hypothesis tests). RESULTS: Of 1,694 academic urologists from 137 institutions, 308 were women (18%). Median years since first publication was 20 for men (IQR 13, 29) and 13 for women (IQR 8, 17). Among all academic urologists, the median h-index was 8 points higher for men (15 [IQR 7, 27]) vs women (7 [IQR 5, 12]). There was no significant gender difference in h-index for any of the subspecialties after adjusting for urologist experience and after applying the Holm method for multiplicity correction. CONCLUSIONS: We were unable to demonstrate a gender difference in h-index after adjusting for urologist experience for any urological subspecialties. Future study is warranted as women become more senior members of the urological workforce.

Evaluation and treatment of pelvic organ prolapse.

Pelvic organ prolapse is a common condition that can have a large impact on a patient's quality of life. Patients with prolapse may present with a vaginal bulge or pressure, bladder, bowel, or sexual symptoms. The diagnosis is confirmed on physical examination which may show descent of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff in those with a prior hysterectomy), posterior vaginal wall, or a combination of these. Patients with asymptomatic prolapse can typically be reassured that it may be managed with observation, though might gradually progress with time. In patients with symptomatic prolapse, management options include conservative measures, pessary use, or surgical intervention. Pessaries can successfully be fitted for most patients that prefer this line of therapy. Surgical interventions include native tissue transvaginal surgeries or a transabdominal (laparoscopic or robotic) approach with use of polypropylene mesh. The choice of surgical procedure includes consideration of an individual's medical and surgical history, physical exam findings, differences in the risks and durability of the operations, and the patient's preference. Ultimately, the surgical plan is based on shared decision making with the patient to best achieve their treatment goals. In this article we will review pertinent clinical considerations in the diagnosis, evaluation, and management of pelvic organ prolapse.

Robotic repair of a branching vesicouterine and vesicovaginal fistula.

INTRODUCTION AND HYPOTHESIS: We present technical considerations and tips for repairing a complex branching vesicouterine and vesicovaginal fistula via a robotic approach. METHODS: A 31-year-old female presented with constant urinary leakage following a vaginal birth after prior cesarean section. Evaluation with cystoscopy and cross-sectional imaging demonstrated a branching vesicouterine and vesicovaginal fistula. Repair with robotic-assisted approach was carried out. An intentional cystotomy was made with a tear-drop incision around the fistula tracts. The vesicouterine and vesicovaginal planes were dissected and mobilized. The vaginotomy and cystotomy were closed in a running two-layer fashion with absorbable suture and the uterine defect closed with interrupted absorbable suture. Retrograde bladder filling confirmed a watertight repair. A broad peritoneal flap was created, positioned, and secured with care to ensure it covered past the apex of the fistula closure. RESULTS: Following overnight observation she had an uneventful recovery, including catheter removal at 3 weeks after cystogram confirmed resolution of the fistula. At 6 weeks the fistula and her leakage remained resolved, with no de novo voiding or incontinence symptoms. CONCLUSIONS: A robotic approach to complex branching vesicouterine and vesicovaginal fistula is technically feasible. Careful attention to surgical technique and the use of tissue interposition may improve fistula resolution rates.

Tonic, Burst, and Burst-Cycle Spinal Cord Stimulation Lead to Differential Brain Activation Patterns as Detected by Functional Magnetic Resonance Imaging.

OBJECTIVE: The objective of this preclinical study was to examine the responses of the brain to noxious stimulation in the presence and absence of different modes of spinal cord stimulation (SCS) using blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD-fMRI). MATERIALS AND METHODS: Sprague-Dawley rats were randomized to groups based on the mode of SCS delivered which included tonic stimulation (n = 27), burst stimulation (n = 30), and burst-cycle stimulation (n = 29). The control (sham) group (n = 28) received no SCS. The SCS electrode was inserted between T10 and T12 spinal levels prior to fMRI session. The experimental protocol for fMRI acquisition consisted of an initial noxious stimulation phase, a treatment phase wherein the SCS was turned on concurrently with noxious stimulation, and a residual effect phase wherein the noxious stimulation alone was turned on. The responses were statistically analyzed through paired t-test and the results were presented as z-scores for the quantitative analysis of the fMRI data. RESULTS: The treatment with different SCS modes attenuated the BOLD brain responses to noxious hindlimb stimulation. The tonic, burst, and burst-cycle SCS treatment attenuated BOLD responses in the caudate putamen (CPu), insula (In), and secondary somatosensory cortex (S2). There was little to no corresponding change in sham control in these three regions. The burst and burst-cycle SCS demonstrated greater attenuation of BOLD signals in CPu, In, and S2 compared to tonic stimulation. CONCLUSION: The high-resolution fMRI study using a rat model demonstrated the potential of different SCS modes to act on several pain-matrix-related regions of the brain in response to noxious stimulation. The burst and burst-cycle SCS exhibited greater brain activity reduction in response to noxious hindlimb stimulation in the caudate putamen, insula, and secondary somatosensory cortex compared to tonic stimulation.