Cosmetic and functional impact of fascia lata harvest for use in surgery for stress urinary incontinence.

INTRODUCTION: There has been increased interest in using autologous tissues since the Food and Drug Administration banned transvaginal mesh for pelvic organ prolapse in 2019. Our study aims to assess patients' perspective of functional and cosmetic impact on the fascia lata harvest site in patients undergoing fascia lata harvest for the treatment of stress urinary incontinence (SUI). METHODS: This is a prospective survey study of a retrospective cohort of patients who underwent a fascia lata pubovaginal sling between 2017 and 2022. Participants completed a survey regarding the functional and cosmetic outcomes of the harvest site. RESULTS: Seventy-two patients met the inclusion criteria. Twenty-nine patients completed the survey for a completion rate of 40.3%. For functional symptoms, 24.1% (7/29) of patients reported leg discomfort, 10.3% (3/29) reported leg weakness, 10.3% (3/29) reported a bulge, 17.2% (5/29) reported scar pain, 14.8% (4/27) reported scar numbness, and 17.2% (5/29) reported paresthesia at the scar. For cosmetic outcomes, 72.4% (21/29) reported an excellent or good scar appearance. On the PGI-I, 75.9% (22/29) reported their condition as very much better (48.3%, 14/29) or much better (27.6%, 8/29). CONCLUSIONS: The majority of patients reported being satisfied with the functional and cosmetic outcomes of their harvest site as well as satisfied with the improvement in their SUI. Less than 25% of patients report harvest site symptoms, including leg weakness, scar bulging, scar pain, scar numbness, or paresthesia in the scar. This is important in the context of appropriate preoperative discussion and counseling regarding fascia lata harvest.

Current Utilization and Perceptions of Formal Education of Point-of-care Ultrasound in Urology.

OBJECTIVE: To assess the extent of formal point-of-care ultrasound (POCUS) training, current utilization of POCUS, and contemporary perceptions of POCUS amongst urologists. METHODS: A survey including questions regarding demographics, prior ultrasound education, current ultrasound utilization in practice/training, perceived optimal POCUS utilization, and the perception of formal ultrasound training was developed. The survey was disseminated to residency program directors (PDs) via the SAU and members of AUA subsection organizations. Data were collected via Redcap. RESULTS: A total of 40 PDs and 159 other respondents completed the survey with approximately half (51%) in an academic practice and two-thirds (68%) with more than 10years in practice. PD response rate was 28%, and general response rate was 2%. Among all respondents, 95% (186/196) and 82% (160/194) agreed/strongly agreed formal POCUS training would be worthwhile during and after residency. Among urology residency PDs, 93% (37/40) agreed/strongly agreed that formal POCUS training is worthwhile in residency. The majority of respondents used some form of ultrasound in practice (77%, 154/199). However, only 37% (72/199) of all respondents had prior formal POCUS training, and 19% (5/26) of PDs reported formal training in their programs. Of respondents without formal training, 63% (80/127) reported interest in pursuing formal training. CONCLUSION: POCUS is widely utilized in many practices. Yet, most urologists have not participated in formal POCUS training and most programs do not have curricula. Urologists have favorable opinions of the utility, safety, and efficacy of POCUS and desire training.

Successful Integration of Blinded Interviews for Resident Selection: Applicant and Faculty Perspective.

OBJECTIVE: To evaluate interviewer and interviewee perceptions of semiblinded interviews performed during 2021-2022 and 2022-2023 urology matches at our institution. Traditional interviews, where interviewers have access to the entire application, are open to significant bias. Blinded interviews are common in industry but under explored in resident selection. METHODS: Interviewers had access to a limited portion of the application (personal statement and letters of recommendation). Applicants were ranked by faculty based solely on their interview and these documents. Following the interview, a survey was given to applicants and faculty regarding their experience. RESULTS: A total of 67 applicants and 10 faculty responded to the questionnaire. Among applicants, 51% felt that blinding of interviewers offered a better assessment of fit into our program (39% neutral), while 37% felt they had improved eye contact with the interviewer (51% neutral) and that interviewers had improved (66%) or similar (19%) knowledge of their application in relation to nonblinded interviews. All but one faculty member felt able to accurately assess a candidate with the information provided, and 80% felt that the blinded interview allowed them to focus more on the applicant during the interview (20% neutral). CONCLUSION: Semiblinded interviews allow for accurate assessment of applicants and decrease bias in the interview process. Overall applicants and faculty were highly receptive to blinded interviews. Reducing the amount of information available to the interviewer allowed them to spend more time on the materials provided, leading to both improved eye contact and improved engagement between participants.

Effect of Holistic Review, Interview Blinding, and Structured Questions in Resident Selection: Can we Predict Who Will Do Well in a Residency Interview?

OBJECTIVE: To examine the Urology residency application process, particularly the interview. Historically, the residency interview has been vulnerable to bias and not determined to be a predictor of future residency performance. Our goal is to determine the relationship between pre-interview metrics and post-interview ranking using best practices for Urology resident selection including holistic review, blinded interviews, and structured behaviorally anchored questions. METHODS: Applications were assessed on cognitive (Alpha Omega Alpha, class rank, junior year clinical clerkship grades) and non-cognitive attributes (letters of recommendation [LOR], personal statement [PS], demographics, research, personal characteristics) by reviewers blinded to USMLE scores and photograph. Interviewers were blinded to the application other than PS and LORs. Interviews consisted of a structured behaviorally anchored question (SBI) and an unstructured interview (UI). Odds ratios were determined comparing pre-interview and interview impressions. RESULTS: Fifty-one applicants were included in the analysis. USMLE step 1 score (average 245) was associated with Alpha Omega Alpha, class rank, junior year clinical clerkship, and PS. The UI score was associated with the LOR (P = .04) whereas SBI scores were not (P = .5). Faculty rank was associated with SBI, UI, and overall interview (OI) scores (P < .001). Faculty rank was also associated with LOR. Resident impression of interviewees were associated with faculty interview scores (P = .001) and faculty rank (P < .001). CONCLUSION: Traditional interviews may be biased toward application materials and may be balanced with behavioral questions. While Step 1 score does not offer additional information over other PI metrics, blinded interviews may offer discriminant validity over a PI rubric.

Evaluating the Whole Applicant: Use of Situational Judgment Testing and Personality Testing to Address Disparities in Resident Selection.

PURPOSE OF REVIEW: Urology program directors are faced with increasing numbers of applications annually, making holistic review of each candidate progressively more difficult. Efforts to streamline evaluation using traditional cognitive metrics have fallen short as these do not predict overall resident performance. Situational judgment tests (SJTs) and personality assessment tools (PATs) have been used in business and industry for decades to evaluate candidates and measure non-cognitive attributes that better predict subsequent performance. The purpose of this review is to describe what these assessments are and the current literature on the use of these metrics in medical education. RECENT FINDINGS: SJTs relative to PATs have more original research. Data suggests that SJTs decrease bias, increase diversity, and may be predictive of performance in residency. PATs are also emerging with data to support use with ability to assess fit to program and certain traits identified more consistently among high-performing residents and correlation to performance on ACGME milestones. PATs may be more coachable than SJTs. SJTs and PATs are emerging as techniques to supplement the current resident application review process. Early evidence supports their use in undergraduate medical education as does some early preliminary results in graduate medical education.

Urethral Pathology in Women.

PURPOSE OF REVIEW: This paper describes the differences in benign, malignant, and iatrogenic urethral pathology in women and reviews common presenting symptoms and management strategies. RECENT FINDINGS: The advancement of magnetic resonance imaging has led to MRI becoming the imaging modality of choice for urethral pathology. Urethral pathology is rare, and there remains a paucity of evidence-based literature for management. Urologists and gynecologists must be familiar with common benign urethral pathology, the most common of which includes urethral diverticula, Skene's gland cyst, urethral prolapse, and caruncle. Further case series are providing further insights to the management of these rare entities. Urologists and gynecologists must understand the most common urethral pathologies and be able to identify the most appropriate treatment approach. It is essential to be able to differentiate these entities from malignancy and obtain a thorough surgical history to identify possible iatrogenic causes.

Does Antimicrobial Prophylaxis in Patients with Specific Comorbidities Reduce the Risk of Infection after Simple Cystourethroscopy?

INTRODUCTION: We evaluated whether antimicrobial prophylaxis decreases rates of post-procedural infection (urinary tract infection or sepsis) after simple cystourethroscopy for patients with specific comorbidities. METHODS: We utilized Epic® reporting software to conduct a retrospective review of all simple cystourethroscopy procedures performed by providers in our urology department from August 4, 2014 to December 31, 2019. Data collected included patient comorbidities, antimicrobial prophylaxis administration and incidence of post-procedural infection. Mixed effects logistic regression models were utilized to estimate the effects of antimicrobial prophylaxis and patient comorbidities on the odds of post-procedural infection. RESULTS: Antimicrobial prophylaxis was given for 7,001 (78%) of 8,997 simple cystourethroscopy procedures. Overall, 83 (0.9%) post-procedural infections occurred. The estimated odds of post-procedural infection were lower when antimicrobial prophylaxis was given compared to those without prophylaxis (OR 0.51, 95% CI 0.35-0.76; p <0.01). The number needed to treat with antimicrobial prophylaxis to prevent 1 post-procedural infection was 100. None of the comorbidities evaluated showed significant benefit from antimicrobial prophylaxis for prevention of post-procedural infection. CONCLUSIONS: Overall, the rate of post-procedural infection after simple office cystourethroscopy was low (0.9%). Though antimicrobial prophylaxis decreased the odds of post-procedural infection overall, the number needed to treat was high (100). Antibiotic prophylaxis was not shown to significantly reduce the risk of post-procedural infection in any of the comorbidity groups we evaluated. These findings suggest that the comorbidities evaluated in this study should not be used to recommend antibiotic prophylaxis for simple cystourethroscopy.

Tethered spinal cord syndrome in adults in the MRI era: recognition, pathology, and long-term objective outcomes.

OBJECTIVE: Tethered cord syndrome (TCS) has been well described in pediatric patients. Many recent reports of TCS in adult patients have grouped retethering patients with newly diagnosed ones without separately analyzing each entity and outcome. The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology, and individual objective outcomes. METHODS: This study included 24 adult patients (20 female and 4 male) who fit the criteria of being newly diagnosed and aged 20 years and older (age range 20-77 years). Preexisting dermal sinus was present in 6 patients, hypertrichosis in 5, skin tag/cleft/dimple and fatty subcutaneous masses in 5, scoliosis in 2, and neurological abnormalities in 4 patients. The pathology consisted of TCS with taut filum in 8 patients, conus lipoma with TCS in 7, diastematomyelia in 7, and cervical cord tethering in 2 patients. Of the 24 study patients, nondermatomal low-back or perineal pain occurred in 19 patients, bladder dysfunction in 21, and motor, sensory, and reflex abnormalities in 21 patients. Aggravating factors were repeated stretching, multiple pregnancies, heavy lifting, and repeated bending. Urological evaluation included bladder capacity, emptying, postvoid residuals, detrusor function, pelvic floor electromyography (EMG), bladder sensitivity, and sphincter EMG, which were repeated at 6 months and 1 year postoperatively. The follow-up was 1 to 30 years. Detailed postoperative neurological findings and separate patient outcome evaluations were recorded. Four of the 24 patients did not have an operation. RESULTS: Resolution of pain occurred in 16 of the 19 patients reporting low-back or perineal pain. Motor and sensory complaints resolved in 17 of 20 patients. Regarding bladder dysfunction, in the 20 patients with available data, bladder function returned to normal in 12 patients, improved in 3 patients, and was unchanged in 5 patients. If the symptom duration was less than 6-8 months, there was recovery of all parameters of pain, bladder dysfunction, and neurological deficit, and recovery from hyperreflexia matched that from neurological deficit. Fifteen patients were employed preoperatively and returned to work, and an additional 3 others who were unable to work preoperatively were able to do so postoperatively. CONCLUSIONS: Most adults with newly diagnosed TCS have unrecognized neurocutaneous abnormalities and neurological deficits. The triad of nondermatomal sacral or perineal pain, bladder dysfunction, and neurological deficit should not be confused with hip or degenerative lumbosacral disease. Addressing the primary pathology often leads to successful results.

Performing Medical Education Research in Urology: Challenges and Opportunities.

PURPOSE OF REVIEW: The Accreditation Council for Graduate Medical Education (ACGME) mandates educating resident physicians in evidence-based medicine (EBM) as a core program requirement. However, despite the significant emphasis placed on EBM, graduate medical education is far from evidence-based, and urology is a specialty where medical education research (MER) is particularly sparse. We want to articulate the challenges and opportunities with performing meaningful medical education research in urology training programs. RECENT FINDINGS: Some studies suggest that the rigor of MER could be much stronger. The nature of GME requires researchers to use alternative study designs. Further, the unique role of residents as both learner and study subject and the dual role of faculty as researcher and educator pose challenges to carrying out research. There is a tremendous opportunity for improvement and innovation in both quality and efficiency of urology resident education. Rigorous MER is required to advance this opportunity, and the fundamental key is development of mentors and collaboration.

A timeline of female stress urinary incontinence: how technology defined theory and advanced treatment.

BACKGROUND: Prevailing theories and treatments of female stress urinary incontinence are built on 120 years of evolution in understanding the structure and function of the female bladder neck and urethra and of considering why treatments failed. In our management of patients, it is important to understand and appreciate how our management of female stress urinary incontinence has evolved and which treatments have prevailed as we advance our knowledge for future treatments. AIMS: The purpose of this review is to describe how advances in technology impacted and shaped prevailing theories or understanding of the pathophysiology of stress urinary incontinence and influences our treatment approach. MATERIALS AND METHODS: An extensive literature search was performed from 1900 to present identifying articles that discussed technological advancements in female urology, theories of female stress incontinence, and treatments. RESULTS: The literature from the 20th century to the present shows a nonlinear evolution of the pathophysiological mechanism of stress urinary incontinence (SUI) from a notion of SUI and secondary to a simple anatomic finding to consideration of the effects of neurophysiologic pathways on SUI. Slings, however, have been a staple in the management of SUI. CONCLUSIONS: The pubovaginal sling (PVS) is a procedure that, with minor modifications (graft size, suture preference) has withstood the test of time and maintained its place in the armamentarium of SUI treatment for 100 years. It is therefore imperative that we continue to educate our residents and fellows on the surgical techniques and indications for use of the PVS.

Urinary tract infection and drug-resistant urinary tract infection after intradetrusor onabotulinumtoxinA injection versus sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX) and sacral neuromodulation (SNM) are effective treatments for refractory urgency urinary incontinence/overactive bladder (UUI/OAB). BTX carries a risk of urinary tract infection (UTI), which is concerning for the development of multidrug resistant (MDR) UTI. We hypothesized that BTX might carry a higher risk of UTI and MDR UTI compared with SNM and that UTI and MDR UTI risk might increase after repeat BTX injection. METHODS: This retrospective cohort study included women undergoing BTX or SNM for refractory UUI/OAB in 2012-2016. UTI and MDR UTI were assessed up to 1 year post-treatment or until repeat treatment and compared between initial BTX and SNM and between repeat BTX injections. Univariate analyses included Chi-squared and Fisher's exact tests and generalized linear models (GLM) with logit link function. Multivariate analyses used GLM to assess the best predictor variables for any UTI. RESULTS: One hundred and one patients were included (28 BTX, 73 SNM). Rates of UTI (39.3% [95% CI 21.5, 59.4] BTX vs 37.0% [95% CI 26.0, 49.1] SNM) were similar in the two groups at all time intervals. One MDR UTI occurred after SNM. Risk of UTI did not increase with repeat BTX (11 out of 28 [39.3%], 6 out of 17 [35.3%], and 4 out of 7 [57.1%] after 1, 2, and ≥ 3 treatments respectively; p = 0.62). Multivariate analysis found that history of recurrent UTI (OR 2.5, 95%CI 0.98-6.39) and prolapse repair (OR 4.6, 95%CI 1.23-17.07) had increased odds of UTI. CONCLUSIONS: Rates of UTI were similar in patients undergoing BTX and SNM. MDR UTI was rare. Patients with prior prolapse repair or recurrent UTI may be at a higher risk of UTI after either procedure.

Sacrocolpopexy: Surgical Technique, Outcomes, and Complications.

PURPOSE OF REVIEW: Pelvic organ prolapse is a non-life-threatening condition that has a wide variety of symptoms. Sacrocolpopexy has been the "gold standard" for management of apical pelvic organ prolapse with reported high success rates for anatomic correction. Herein, we review the surgical procedure, anatomic, and functional outcomes, as well as the intraoperative and postoperative complications. RECENT FINDINGS: Findings suggest that the ASC has an acceptably low overall complication rate comparable between open and minimally invasive approach. Mesh extrusion and anatomic failure have been shown to increase over time. Patient education and counseling are important preoperatively. It is important to discuss with the patient risks of the surgical procedure, specifically mesh-related extrusion, longer term anatomic recurrence rates, rates of functional improvement, or worsening of bladder and bowel symptoms, as well as rates of dyspareunia.

Prostatitis: diagnosis and treatment.

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.

Minimally invasive treatment of stress urinary incontinence and vaginal prolapse.

Stress urinary incontinence and pelvic organ prolapse are prevalent conditions that can have detrimental effects on a woman's quality of life. Surgically, this has often been approached by means of a transvaginal route. With recent advances in laparoscopic and robotic instrumentation and operating systems, there is increasing interest in minimally invasive techniques for correction of pelvic organ prolapse. In this article, the authors briefly describe the laparoscopic and robotic approaches in terms of surgical techniques, operative anatomy, and results published in the literature.

Recommendations for urodynamic assessment in the evaluation of women with stress urinary incontinence.

Urinary incontinence is a common problem that is experienced by women of all ages. The overall evaluation and treatment of incontinence has increased in sophistication, both as a result of the introduction of urodynamic testing in the assessment of patients, and because there are increasing numbers of medical and surgical treatments available for incontinence. What was previously considered a personal problem for women, and which was rarely discussed, has become a more open and acceptable complaint for female patients to bring to their physicians. This Review aims to clarify when urodynamic testing is clearly indicated for patients with symptoms of stress urinary incontinence, and describes the current recommendations from three national and international governing bodies. This Review will also highlight some of the ongoing debates over the performance, interpretation, and utility of urodynamic testing, and provide references for further reading on these topics.

Induction of protective immunity to RM-1 prostate cancer cells with ALVAC-IL-2/IL-12/TNF-alpha combination therapy.

Human prostate cancers characteristically express low levels of major histocompatibility complex (MHC) Class I, which makes it challenging to induce protective antitumor responses involving T cells. Here we demonstrate that a whole cell tumor vaccine can induce protective T cell immunity to a low MHC Class I-expressing mouse prostate cancer cell line, RM-1. ALVAC recombinant canarypox viruses encoding interleukin-2, interleukin-12 and tumor necrosis factor-alpha were used to create therapeutic vaccines in 2 different ways. The RM-1 cells were pre-infected in vitro with the viruses prior to injection (pre-infection vaccine) or the RM-1 cells were injected alone, followed by the viruses (separate injection vaccine). The vaccines were each tested subcutaneously or intradermally. The pre-infection vaccine resulted in 100% clearance of primary tumors, whereas intradermal delivery of the separate injection vaccine cleared 40-60% of primary tumors. Despite the highly efficient primary tumor clearance by the pre-infection vaccine, only the separate injection vaccine generated protection upon rechallenge. Tumor-free survival induced by the separate injection vaccine required natural killer (NK) cells, CD4(+), and CD8(+) T cells. None of these cells alone were sufficient to induce tumor-free survival to the primary challenge, demonstrating an important cooperativity between NK cells and T cells. Secondary clearance of tumors also required NK and CD8(+) T cells, but not CD4(+) T cells. We report for the first time the generation of T cell immunity to the RM-1 prostate cancer cell line, demonstrating that it is possible to generate protective T cell immunity to a MHC I-low expressing tumor.