The role of a photographic atlas in reducing unanticipated healthcare utilization following circumcision.

INTRODUCTION: Circumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies. MATERIALS AND METHODS: In this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED. RESULTS: The retrospective no-atlas cohort included 105 patients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p = 0.47) and other demographics. There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no difference in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p = 0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p = 0.41). DISCUSSION: The use of a photographic atlas as part of caregiver support for circumcision patients did not demonstrate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of significant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other potential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study. CONCLUSIONS: Adding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utilization in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.

A single-institution experience of complete primary repair of bladder exstrophy in girls: risk factors for urinary retention.

INTRODUCTION: Historically after complete primary repair of exstrophy (CPRE) in girls, it had been more likely to observe urinary incontinence than retention. Following recent technical modifications of elongating the urethra and narrowing the bladder neck, the authors have observed a high rate of urinary retention in girls after CPRE. OBJECTIVE: The aim was to identify factors that may be responsible for this observation by reviewing historical and current outcomes. The authors hypothesized that differences in anatomic dimensions at the time of CPRE may contribute to urinary retention. STUDY DESIGN: A retrospective review of girls who underwent CPRE from December 1998 through September 2016 from a single institution was performed. Patients were deemed in retention if their clinical course was consistent with such, required a procedure to relieve urinary retention, and/or required clean intermittent catheterization. RESULTS: Nineteen girls underwent CPRE during this period. In 2012, a change to delaying CPRE to approximately 2 months of age was made, and this led the authors to divide their experience into CPRE performed as a newborn (<72 h of age, 8 patients) versus delayed (>72 h, 11 patients) subgroups. There were no girls with retention in the newborn group and three (38%) girls with retention in the delayed group. In the delayed group, girls had a longer urethral plate and narrower bladder neck compared with the newborn group. Long-term outcomes greater than 9 years are available for six girls in the newborn group and two (33%) required bladder neck procedures for incontinence. None in the delayed group have required incontinence procedures; however, follow-up is limited at 25 months. DISCUSSION: The absence of retention in the newborn group is concerning for the delayed group incurring a higher risk of retention after CPRE. This may be secondary to excessive compression of the urethra at the time of pubic symphysis approximation potentially leading to urethral ischemia. Different from the newborn CPRE girls, additional technical revision of CPRE, namely, elongation of the urethra and the dissection it involves and narrowing of the bladder neck, may increase the risk for retention. CONCLUSIONS: The multiple factors that were identified as potential contributors to post-CPRE urinary retention should result in a cautious reevaluation of female bladder exstrophy management at the time of CPRE. The authors now create a gradual tapered transition at the bladder neck and, similar to their previous experience, a more generous (wider) bladder neck and a shorter length for urethral plate.

Uncharted territory: navigating the pediatric urology job market.

INTRODUCTION: There is not a structured algorithm, timeline, or resource on how, when, and which programs are looking for a new staff pediatric urologist. We hypothesized that current and future pediatric urology fellows could benefit from the experiences of recently graduated fellows on navigating the urology job market. OBJECTIVE: The purpose of this study was to survey current and recent pediatric urology fellowship graduates about the process of finding their first job. STUDY DESIGN: A Research Electronic Data Capture (REDCap) online survey was designed and distributed through email to current fellows and 2012-2017 graduates. Results were evaluated using STATA. RESULTS: 153 participants were emailed, and 94 (61%) completed the survey. The plurality of applicants (44%) began the job search at the Spring American Urological Association meeting, 14 months before finishing (Figure). Of those who started 14 months before finishing, 33% wished they started earlier and 61% would have started at the same point. The median number of programs contacted for a position was 3-4 and the median number of programs visited and offers received was two. After the offer, 40% reported having >8 weeks to decide. Less than half (38.5%) hired an attorney for contract negotiation. Of those who hired an attorney, 68% felt it provided benefit. Regarding contract negotiation, 22% did not negotiate and 35% negotiated for salary. Unsurprisingly, 28% of those who took academic jobs thought negotiating for protected research/educational time was most important compared with only 4% of those who took non-academic jobs (P = 0.02). When asked how they learned about the job they accepted: 28% were contacted by the program, 25% cold called the program, 30% accepted where they did residency or fellowship, and 18% learned through society websites. The plurality (50%) thought the number of desirable positions during the process were as they expected. 41% however, thought the number of desirable positions were expectedly or surprisingly low. Regarding quality of life and satisfaction with job/career choice, 98% stated that they would still choose to subspecialize in pediatric urology. CONCLUSIONS: The results from this survey should provide guidance to fellows on how to approach the job search with respect to timing, expectations, contract negotiation, and initial job satisfaction.