Understanding the prevalence and distribution of fellowship trained female and male genitourinary reconstruction and men's health/andrology academic faculty in the United States.

Background: We evaluated the prevalence, distribution, and specialist to population ratio of male and female reconstruction and andrology/prosthetics faculty within United States urologic training programs. Our objective was to help determine the current need/demand for reconstructive fellowship trained faculty for necessary clinical exposure during residency in the midst of a nationwide residency expansion. Methods: All non-military urology residency programs were evaluated. Programs were sorted into their American Urologic Association Sections and websites were analyzed for evidence of fellowship training and/or clinical expertise/interest: (I) male genitourinary reconstruction (MGR); (II) female genitourinary reconstruction (FGR) and (III) infertility/andrology/men's health (AMH). The 2020 US Census data was used to determine specialist to population ratios by sections. Results: Of 137 evaluated programs, FGR had the highest percentage of fellowship-trained faculty (76%) followed by AMH (66%) and MGR (61%). Clinical/surgical interest was noted in pelvic organ prolapse (88%), inflatable penile prosthesis (79%) and urethral stricture disease (75%). Over 10% of training programs had two or more faculty with MGR, FGR and AMH fellowship training. Significant geographic variation amongst academic programs exists with the South and Southeastern parts of the US being relatively underserved, both in percentage of programs with fellowship-trained faculty, and by faculty per 1,000,000 inhabitants. Conclusions: The majority of US urology residencies have faculty with fellowship training and/or stated clinical interest in MGR, FGR and AMH. Still, many programs remain without these faculty while others have two or more in their respective fields. The geographic trends noted here have both educational and recruitment significance.

Factors Influencing Underrepresented in Medicine Urologist Recruitment to Academic Institutions.

INTRODUCTION: We characterize factors associated with recruitment of underrepresented in medicine urology trainees and faculty to academic institutions given the excessive disparity between urology and other fields of medicine. METHODS: A database of urology faculty and residents in Accreditation Council for Graduate Medical Education programs was created. Demographic data were obtained from departmental websites, Twitter, LinkedIn, and Doximity. Program prestige was defined by U.S. News and World Report rankings. Program location and city size were determined using the U.S. Census data. Multivariable analysis was performed assessing the association of gender, AUA section, city size, and rankings on underrepresented in medicine recruitment. RESULTS: Of urologists in this study 8.7% were underrepresented in medicine status. More women urologists were underrepresented in medicine (31.4%) than non-underrepresented in medicine (21.3%; P < .001). Factors predictive of more underrepresented in medicine urologists were practice in South Central AUA section (OR 2.1, P = .04), and medium metro areas (OR 1.6, P < .01). Among residents, factors predictive of more underrepresented in medicine urologists were female gender (P < .001), living in medium metro areas (P = .03), and training in top 10 programs (P = .001). Underrepresented in medicine faculty were more likely to be women compared to non-underrepresented in medicine faculty (P = .05). Pearson correlation test found no association between the presence of underrepresented in medicine faculty and underrepresented in medicine residents (r = 0.20). CONCLUSIONS: Underrepresented in medicine urology residents and faculty were more likely to be women, compared to non-underrepresented in medicine residents and faculty. Underrepresented in medicine residents are more prevalent in medium metro areas and in top 10 programs. More underrepresented in medicine faculty status was not associated with more underrepresented in medicine residents.

India Ink Tattooing of Ureteroenteric Anastomoses.

While upper tract access through the insensate conduit following urinary diversion takes less time and incurs fewer costs than percutaneous kidney access does for the treatment of ureter and kidney pathology, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink into the bowel mucosa near the UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing. Patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections. The injections were placed 1 cm from UEA in a triangular configuration, and loopogram exams and looposcopy were performed to identify reflux (UR), UEA, the tattooing site and strictures in 10 and 11 patients randomized with respect to ink and NS injections, respectively. Ink patients were older (72 vs. 61 years old, p = 0.04) and had a higher Charlson Comorbidity Index (5 vs. 2, p = 0.01). Looposcopy was performed in three ink and four NS patients. Visualization of UEA was achieved in 100% of the ink and 75% of the NS patients (p = 0.26). The ink ureteroenteric anastomotic stricture (UEAS) rate was higher (N = 3 vs. N = 1) and six patients vs. one patients underwent surgery, respectively, for UEAS (p = 0.31). The study was halted early due to safety concerns. Our pilot study demonstrates that ink can be well visualized following injection near UEA during IC. However, the ink cohort had more UEAS than previously cited in the literature and our prior institutional UEAS rate of 6%. While this study sample is small, the higher incidence of UEAS after ink injection led us to question the utility and safety of ink injection following IC.

Pediatric urologists' confidence and accuracy in estimating penile curvature.

BACKGROUND: Assessment and management of congenital penile curvature (PC) can be variable. Methods for correction of PC usually are dependent on degree of PC which is reliant on how degree is assessed. We sought to assess the confidence and accuracy of measuring PC and hence management using case-based examples. METHODS: A survey was emailed to members of the Societies for Pediatric Urology. Demographic information, management strategies for PC, and self-reported confidence in measuring PC were assessed. A Likert scale measured self-confidence. Case scenarios were used to assess ability to measure PC and methods of correction. The cases consisted of three computer-generated penis model images with arc-type ventral curvature and one image of lateral curvature in an infant. RESULTS: The response rate was 30% (108/355). The mean confidence score was 3.6 ± 0.8 (3-fairly confident; 4-very confident). In clinic, 89% of urologists used eyeball estimates to assess PC; 5% used both eyeball and goniometer. In the operating room, 71% used eyeball estimates, 8% used goniometer, and 16% used both. If sole decision-maker, urologists recommend surgical correction of PC over observation at median 30° (IQR 21-30°). At a median of 45°, there was a shift in corrective surgical preference from dorsal plication (DP) (IQR 30-54°) to ventral lengthening (IQR 34-60°). Urologists underestimated PC degree for all cases (summary table). For all cases, there was no association between years in practice or confidence level on estimated PC degree. In case 1, only 24% of urologists would correct a mean estimate of 23° PC; those who would correct had a higher mean PC estimate vs those who would not (28° vs 21°, p < 0.001). Case 2 and 4 had similar estimations and correction methods. In case 2, those who chose VL had a higher mean PC estimate vs those who did not (43° vs 37°, p < 0.01), but no estimate difference was seen for DP (p = 0.52). In case 4 with lateral PC, those who chose DP had a higher mean PC estimate vs those who did not (41° vs 33°, p = 0.049). Yet in case 3, there was no difference in PC estimate in urologists who chose VL vs not (57° vs 53°, p = 0.16). CONCLUSIONS: A uniform underestimation of PC existed despite self-reported confidence in the ability to measure PC. An increasing willingness to perform surgical correction was demonstrated with a shift towards VL for ventral curvature and less so for lateral curvature as PC worsens.

Complex Foley Catheter Placement After Radical Prostatectomy.

OBJECTIVE: To describe a method for replacement of a dislodged critical urethral foley catheter following a robotic- assisted laparoscopic radical prostatectomy. BACKGROUND: Following robotic-assisted laparoscopic radical prostatectomy (RALP), a bladder drainage via catheter is necessary to allow for proper healing of the urethrovesical anastomosis. In most cases, this is done using a transurethral foley catheter.1,2 Early traumatic loss of the urethral catheter following RALP is consider a urologic emergency and can lead to vesicourethral anastomotic urine leak, ileus, infection or abscess, and future anastomotic stenosis.3 Replacing the urethral catheter in this situation can be difficult even in experienced hands and often requires imaging assistance. METHOD: A 53-year-old male with Grade Group 4 (Gleason 4 + 4) prostate cancer underwent an uncomplicated RALP. During his post-operative course, his urethral foley catheter fell out or was traumatically removed three times resulting in disruption of the posterior anastomosis. To replace the urethral catheter and prevent it from being dislodged again, a transabdominal approach under ultrasound and cystoscopic guidance was employed to replace the catheter into the bladder and secure it trans abdominally using a single G-tube safety Pexy T fastener. CONCLUSION: This case reports describes a technique used to replace and secure a urethral foley catheter in a patient who suffered from a posterior anastomotic disruption following repeated loss and traumatic removal of his urethral foley catheter during his RALP post-operative course. While replacement of a dislodged urethral foley catheter following a RALP can be challenging, the catheter can safely be placed and secured trans abdominally in these rare but serious situations where the conventional catheter secure devices and patient education alone are not sufficient to prevent removal.

Evaluation of the Educational Impact of the Urology Collaborative Online Video Didactics Lecture Series.

OBJECTIVE: To assess the impact of the Urology Collaborative Online Video Didactic (COViD) lecture series series on resident knowledge as a supplement to resident education during the coronavirus disease 2019 pandemic. METHODS: One hundred thirty-nine urology residents were voluntarily recruited from 8 institutions. A 20-question test, based on 5 COViD lectures, was administered before and after watching the lectures. Pre- and posttest scores (percent correct) and score changes (posttest minus pretest score) were assessed considering demographic data and number of lectures watched. Multiple linear regression determined predictors of improved scores. RESULTS: Of residents recruited, 95 and 71 took the pre- and posttests. Median number of lectures watched was 3. There was an overall increase in correct scores from pretest to posttest (45% vs 57%, P < .01). Watching any lectures vs none led to higher posttest scores (60% vs 44%, P < .01) and score changes (+16% vs +1%, P < .01). There was an increase in baseline pretest scores by post-graduate year (PGY) (P < .01); however there were no significant differences in posttest or score changes by PGY. When accounting for lectures watched, PGY, and time between lecture and posttest, being a PGY6 (P = .01) and watching 3-5 lectures (P < .01) had higher overall correct posttest scores. Watching 3-5 lectures led to greater score changes (P < .001-.04). Over 65% of residents stated the COViD lectures had a large or very large impact on their education. CONCLUSIONS: COViD lectures improved overall correct posttest scores and increased knowledge base for all resident levels. Furthermore, lectures largely impacted resident education during the coronavirus disease 2019 pandemic.

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis.

BACKGROUND: Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. METHODS: An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan-Meier analysis of stricture by cancer type. RESULTS: 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). CONCLUSIONS: Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.

Trends in Female Authorship Within Urologic Literature: A Comparison of 2012 and 2017.

OBJECTIVE: To evaluate trends in female authorship in the recent urologic literature. METHODS: We examined articles published in 2012 and 2017 from 5 urologic journals: Journal of Urology, Journal of Endourology, Neurourology and Urodynamics, Urologic Oncology, and Urology. Gender was recorded for first, supplemental, and last authors. Articles were further categorized by subspecialty focus of the published article. Chi-square tests and multiple logistic regression modeling were used to assess for differences in female authorship by year, journal, and article subspecialty. RESULTS: One thousand four hundred and thirty-three and 1374 articles were published in 2012 and 2017, respectively. There was a significant increase in all female authorship categories between years: first (19%-25%), last (12-16%), and any (67%-74%) (P<.01, all). By journal, the highest proportion of articles with any female authors for both years was in Neurourology and Urodynamics (80%, 2012; 85%, 2017) while lowest was in Journal of Endourology (49%, 2012; 54%, 2017). Likewise, female authorship was generally higher in female/voiding dysfunction /incontinence and lower in endourology subspecialty articles. Controlling for journal and subspecialty, multiple logistic regression analysis showed no change in last authorship between years. CONCLUSION: Overall female authorship in the urologic literature has increased in recent years. However, after controlling for journal and subspecialty we found no increase in female last authorship between years, suggesting that disparities in senior authorships exist based on journal and subspecialty topic. Our findings further suggest an authorship plateau, highlighting the importance of efforts to optimize advancement and promotion of women in academic urology.

Publication of Positive Studies in the Urologic Literature.

OBJECTIVE: To assessed rates of positive publications within the urologic literature, comparing the years 2012 and 2017. MATERIALS AND METHODS: All studies published in Journal of Urology, Neurourology and Urodynamics, Urologic Oncology, Journal of Endourology, and Urology in 2012 and 2017 were reviewed. The primary study outcome was proportion of positive studies. Additional article characteristics, including associated citations and subspecialty focus, were recorded and statistical analyses used to assess for differences in negative publication rates based on these variables. RESULTS: A total of 1,796 articles meeting inclusion criteria were analyzed (2012, 959; 2017, 837). The overall proportion of positive studies decreased in comparison of 2012 and 2017. (90%-86%, P =.01). A statistically significant decrease was seen in 2 of 5 journals: Neurourology and Urodynamics (97%-87%, P = .01) and Journal of Endourology (93%-83%, P <.01). There were no significant differences in associated citations for positive vs negative studies in either year. Logistic regression focused on year and journal revealed that studies published in 2017 and Urology were more likely to be negative. CONCLUSION: The vast majority of studies within the urologic literature are positive, with only a small increase in negative study publication comparing 2012 vs 2017. Continued efforts are needed to identify publication bias and promote dissemination of negative research findings.

Urinary Incontinence Research: Compliance With Research Standards for Clinical Studies.

OBJECTIVE: To perform an updated literature review to assess compliance with outcomes use and reporting guidelines. In 1997, the Urodynamics Society recommended standards of efficacy to be used for evaluation of treatment outcomes in urinary incontinence (UI). Studies published shortly after the release of these standards reported generally low rates of adherence. METHODS: We reviewed all 2017 articles related to UI in 3 urologic journals (Journal of Urology [JU], Neurourology and Urodynamics [NU], and Urology [UR]). Articles were assessed for compliance with 19 standards across 3 categories (methodology, pretreatment, and post-treatment). Analysis focused on overall and category specific compliance, as well as comparison of compliance between journals. RESULTS: A total of 78 articles met inclusion criteria for analysis. The mean overall compliance was 52% for all standards. JU demonstrated a higher compliance (63%) as compared to NU (50%) and UR (46%) (P <.01). No articles reviewed demonstrated 100% compliance with all standards. Only 23%, 6%, and 12% of JU, NU, and UR articles, respectively, demonstrated at least 75% compliance with all standards. In comparison of subcategory compliance, JU demonstrated a statistically higher methodology compliance (P <.01). In contrast, compliance with both pre- and post-treatment standards across all 3 journals demonstrated no statistically significant differences. CONCLUSION: Overall, we found that a significant percentage of recent study on UI fails to meet suggested standards for use and reporting of outcomes. These data suggest that continued efforts are needed to improve the quality and reporting of UI research.

Thermal ablation of the small renal mass: a critical analysis of current literature.

INTRODUCTION: Thermal ablation is increasingly utilized as a management strategy for small renal masses (<4 cm). Partial nephrectomy is recognized as the gold standard; thermal ablation has been reserved for older patients with comorbidities due to concern for local tumor recurrence. As long-term data regarding the safety and efficacy of ablative techniques accumulate with encouraging results, clinicians are widening the utility in select patient populations. This review summarizes the currently available technologies in terms of procedural differences, oncologic outcomes, renal function, and complication rates. EVIDENCE ACQUISITION: A structured literature review was conducted using PubMed and Web of Science, using the keywords: "renal cell carcinoma," "ablation techniques," "cryosurgery," "radiofrequency ablation," "microwave ablation," "outcomes assessment," "post-operative complication," and "hospital costs." Articles were reviewed to summarize oncologic outcomes, complications, and impact on renal function of cryoablation, radiofrequency ablation, and microwave ablation. EVIDENCE SYNTHESIS: Thermal ablation is a safe and effective management option for small renal masses in select patients, particularly in those with multiple tumors and/or those unable or unwilling to undergo more invasive surgery. Slightly higher rates of local recurrence rates (~1-10%) with thermal ablation are offset by lower complication rates and reduced morbidity, and equivalent or better renal function outcomes compared to surgery. CONCLUSIONS: The established modalities of cryo-, radiofrequency, and microwave ablation offer equivalent outcomes with similar complication rates; technique choice is primarily based on tumor characteristics and operator preference. Better quality evidence comparing thermal ablation with surgical nephron-sparing intervention is needed to make informed conclusions on efficacy.