Preputial pedicle flap ICG blood flow assessment during proximal hypospadias repair: Development of a standardized protocol.

INTRODUCTION: Blood supply to preputial flap drives outcomes of hypospadias repair. Unfortunately, we only have surgeon's subjective assessment to evaluate flap perfusion which may not be accurate. Indocyanine green (ICG) has been used in a multitude of surgeries for perfusion assessment, however, no standardized protocol has been described for use of ICG in hypospadias repairs. The aim of this study is to develop a standardized protocol of ICG use in proximal hypospadias and establish perfusion patterns of preputial flaps. STUDY DESIGN: A pilot study was conducted using ICG in patients with proximal hypospadias undergoing first stage repair with a preputial flap. The Stryker SPY PHI system and novel quantification software, SPY-QP, were used for ICG imaging. An adaptive approach was taken to develop and implement a standardized protocol (Summary Figure). Per the protocol, ICG was administered at 3 time points which were felt to be critical for assessment of flap perfusion. Of the study patients who have undergone second stage repair, ICG was also used to reassess the flap prior to tubularization of the urethra. RESULTS: A total of 14 patients underwent first stage hypospadias repair with preputial flaps and intraoperative use of ICG. Median ICG uptake of the prepuce after degloving (dose 1) was 58.5% (IQR 43-76). ICG uptake decreased after flap harvest and mobilization (dose 2) with a median ICG uptake of 34% (IQR 26-46). ICG uptake remained stable after securing the flap in place and closing the skin (dose 3) with a median ICG uptake of 34% (IQR 25-48). ICG was able to delineate subtle findings in the preputial flaps not visible to the naked eye and in one case impacted intraoperative decision making. To date, 5 patients have undergone second stage repair. Flap assessment prior to tubularization of the urethra showed hypervascularity with a median ICG uptake of 159%. CONCLUSIONS: A standardized protocol for ICG use in proximal hypospadias was successfully developed and implemented. ICG uptake in the preputial flap decreased with increasing manipulation and mobilization of the flap. ICG was able to detect changes to flap perfusion which were not able to be seen with the naked eye. Reliance on surgeon's subjective assessment of flap perfusion may be inadequate and ICG could provide a useful tool for surgeons to improve preputial flap outcomes. ICG may also enhance the learning experience for trainees and early career urologists in these complex surgeries.

Putting the coach in the game: Current and future state of surgical coaching in pediatric urology.

BACKGROUND: Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program. METHODS: Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership. RESULTS: Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below). CONCLUSIONS: While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.

Standardization and Implementation of a Surgical Coaching Model for Pediatric Urology.

To bridge gaps in proficiency and encourage life-long learning following training, coaching models have been utilized in multiple surgical fields; however, not within pediatric urology. In this review of our methodology, we describe the development of a coaching model at a single institution. In our initial experience, the perceived most beneficial aspect of the program was the goal setting process with logistics around debriefs being the most challenging. With our proposed coaching study, we aim to develop a model based upon prior coaching frameworks,1,2 that is feasible and universally adaptable to allow for further advancement of surgical coaching, particularly within the field of pediatric urology.

Publication misrepresentation among urology residency applicants.

PURPOSE: To assess the extent and types of publication misrepresentation among medical students applying to the urology residency program at the University of Washington. Research experience and publications are the selection criteria used to judge and rank urology residency applicants. METHODS: Electronic Residency Application Service (ERAS) applications submitted for the incoming class of 2011 for urology residency at the University of Washington were reviewed. All listed publications were verified against PubMed and Google search engines. Misrepresentation was defined as non-authorship of an existing article, authorship claimed of a nonexistent article, or first-authorship listed incorrectly. RESULTS: Of the 198 total applications, 124 (63 %) applicants reported 541 publications, including 112 abstracts and 429 journal articles. 347 (65 %) articles and abstracts were verifiable. Misrepresentation of 12 (3.5 %) published articles was found in 9 applicants (7 %), which included self-promotion to first-authorship (6), followed by non-existent articles (5), and a repeated publication listing (1). On univariate analysis, higher age (p = 0.008), higher number of total publications reported (p < 0.001), additional graduate degree (p < 0.001), and foreign medical graduate (FMG) status (p < 0.001) were associated with misrepresentation. Due to the low incidence, the study was not adequately powered to perform a multivariate analysis. CONCLUSIONS: Misrepresentation of publications listed in ERAS among urology applicants remains significant. Residency program directors should require applicants to submit copies of all of their publications, whether in print, in-press, or submitted to be placed as part of their application file.

Reducing post-operative caregiver after-hours phone calls to pediatric urology providers: A quality improvement study.

INTRODUCTION: Caregiver phone calls are an important part of caring for pediatric patients. At our institution, residents respond to after-hours caregiver calls. While it is critical for families to be able to reach us for urgent concerns, the ease of access has led to overutilization with many phone calls not meeting the urgent nature that is intended for these calls. The primary aim of this quality improvement project was to decrease the number of non-urgent caregiver calls after-hours. Our secondary aim was to improve compliance with telephone encounter documentation and to standardize the documentation content. STUDY DESIGN: We conducted a single institution, multiphase quality improvement project. This started with a preintervention phase which included evaluation of our current state, identifying that most calls were for post-operative patients and that our discharge instructions inadequately detailed when caregivers should call. Notes were also inconsistently documented with no standard format. In the first PDSA cycle, launched on November 1, 2021, a standardized note template was created for documentation of caregiver telephone encounters. The PDSA cycle began on January 1, 2022 and included updates to our post-operative instructions with explicit guidance detailing when to call after-hours. Call data from September 2021 to February 2022 was reviewed including variables such as caller demographics, reason for call, and operative details. Primary outcomes were proportion of post-operative calls within 30 days and non-urgent calls. Secondary outcome was proportion of calls documented appropriately. Phases were categorized as current state (Sep/Oct 2021), PDSA cycle 1 (Nov/Dec 2021), PDSA cycle 2 (Jan/Feb 2022). RESULTS: In our current state, the majority of the calls (66%) were for post-operative patients and 59% of all calls during this period were non-urgent. The proportion of post-operative phone calls stayed stable at 67% during PDSA cycle 1, but decreased to 38% with PDSA cycle 2 with implementation of updated post-operative instructions (Summary figure) (p < 0.001). The proportion of non-urgent calls was similar (current state - 68%, PDSA cycle 1 - 72%, PDSA cycle 2-73%, p = 0.39) (Summary figure). Call documentation was also similar with a documentation rate of 79% pre-intervention and 87% post-intervention (p = 0.21) (Summary figure). CONCLUSIONS: With interventions focused on post-operative caregiver instructions, the number of post-operative phone calls decreased. Standardization of documentation was achieved. However, the overall call volume did not change, nor the proportion of non-urgent calls.

Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review.

PURPOSE: This study systematically reviews the uses of electronic health record (EHR) data to measure graduate medical education (GME) trainee competencies. METHOD: In January 2022, the authors conducted a systematic review of original research in MEDLINE from database start to December 31, 2021. The authors searched for articles that used the EHR as their data source and in which the individual GME trainee was the unit of observation and/or unit of analysis. The database query was intentionally broad because an initial survey of pertinent articles identified no unifying Medical Subject Heading terms. Articles were coded and clustered by theme and Accreditation Council for Graduate Medical Education (ACGME) core competency. RESULTS: The database search yielded 3,540 articles, of which 86 met the study inclusion criteria. Articles clustered into 16 themes, the largest of which were trainee condition experience (17 articles), work patterns (16 articles), and continuity of care (12 articles). Five of the ACGME core competencies were represented (patient care and procedural skills, practice-based learning and improvement, systems-based practice, medical knowledge, and professionalism). In addition, 25 articles assessed the clinical learning environment. CONCLUSIONS: This review identified 86 articles that used EHR data to measure individual GME trainee competencies, spanning 16 themes and 6 competencies and revealing marked between-trainee variation. The authors propose a digital learning cycle framework that arranges sequentially the uses of EHR data within the cycle of clinical experiential learning central to GME. Three technical components necessary to unlock the potential of EHR data to improve GME are described: measures, attribution, and visualization. Partnerships between GME programs and informatics departments will be pivotal in realizing this opportunity.

Exploring Barriers to the Inclusion of Underrepresented Minorities in Urology: The Temporal and Financial Costs of Residency Interviews.

OBJECTIVE: To investigate whether interview travel cost and time differed for urology residency applicants from medical schools with higher vs lower proportions of students from groups underrepresented in medicine (URiMs). METHODS: We identified 22 medical schools, 11 with <15% and 11 with >20% URiM students, and 17 "highly ranked" urology residency programs. We contacted the residency programs and requested interview dates, preferred lodging options, and institution-based cost-savings. We constructed interview itineraries for 22 hypothetical students (one from each school), and compared the total cost and time for travel to all 17 interviews. Total travel time and interview costs for the students at schools with <15% and >20% URiM were compared, with findings considered statistically significant at P <.05. RESULTS: Each student was able to attend all 17 interviews. The median total cost was similar for applicants from schools >20% URiM ($8074.80; range: $7027.60-$13702.59) and <15% URiM ($8764.60; range: $6698.48-$11966.83; P = .89). The median aggregate travel time for applicants from schools >20% URiM was 176.4 (range: 93.7-246.2) hours and for applicants from schools <15% URiM was 160.5 (range: 128.2-203.9) hours (P = .62). CONCLUSION: Financial and temporal costs were similar for applicants from medical schools with <15% or >20% URiM students. Thus, absolute cost considerations are unlikely to account for differences in URiM representation in urology. However, the relative impact of interview costs may be different for URiM students. Effective and durable engagement of URiM students in urology requires an introspective assessment of objective vs anecdotal barriers to recruiting and retaining URiM medical students.

Can we rely on the presence of dextranomer-hyaluronic acid copolymer mounds on ultrasound to predict vesicoureteral reflux resolution after injection therapy?

PURPOSE: We determined whether the presence or absence of dextranomer-hyaluronic acid copolymer mounds on bladder ultrasound coincides with voiding cystourethrogram results after injection therapy in children with primary vesicoureteral reflux. MATERIALS AND METHODS: We retrospectively reviewed consecutive cases of dextranomer-hyaluronic acid copolymer injection for primary vesicoureteral reflux. The primary outcome investigated was the appearance of dextranomer-hyaluronic acid copolymer mounds on ultrasound and their association with voiding cystourethrogram results postoperatively. An intramural dextranomer-hyaluronic acid copolymer mound on ultrasound was considered a negative test result for vesicoureteral reflux. RESULTS: A total of 187 cases were identified, of which 132 had imaging available for evaluation. Intramural mounds were seen on ultrasound in 86 cases postoperatively, of which 34 (40%) had a positive voiding cystourethrogram. Of 46 cases in which no mound was identified 21 (46%) had a positive voiding cystourethrogram. The sensitivity of ultrasound to determine the presence or absence of vesicoureteral reflux was 38%, specificity was 67%, accuracy was 55%, the positive predictive value was 46% and the negative predictive value was 60%. CONCLUSIONS: Our results indicate poor correlation of dextranomer-hyaluronic acid copolymer mound appearance on ultrasound with voiding cystourethrogram results after injection. To adequately evaluate for the resolution of vesicoureteral reflux a voiding cystogram or nuclear medicine cystogram needs to be performed after injection therapy.

Program Directors' Perspectives of ACGME Requirements and Effectiveness of Training Urology Residents: A National Survey in the Era of the Next Accreditation System.

OBJECTIVE: To qualitatively assess Urology program directors' perspectives on the effectiveness of training residents after implementation of the Accreditation Council for Graduate Medical Education's (ACGME) 2011 Next Accreditation System, and identify differences in current perspectives and prior surveyed perspectives toward the ACGME Outcome Project. METHODS: A national survey was developed by an ad hoc committee and distributed electronically to 105 Urology program directors. Thirty-four (34) multiple-choice, Likert-scale questions were administered. Data were evaluated and the results from the survey were compared to the one performed 15 years earlier to determine changes in the learning environment and effectiveness of training urology residents. RESULTS: The current survey response rate was 89% which was similar to the 2005 response rate of 88%. Most program directors (61%) agreed that 20% protected time for program directors helped with administrative work and 31% felt this time needs to increase for larger residency programs. Seventy percent (70%) agreed that dedicated program administrator time has helped their program. More than half of the respondents agree that the ACGME is training the current workforce effectively. CONCLUSION: Current program directors appear to be more accepting of changes required by the Next Accreditation System as compared to the Outcome Project 15 years ago. Our study supports the need for protected time to train residents and to overcome barriers to change.

Inter-Resident Variability in Urologic Operative Case Volumes Over Time: A Review of the ACGME Case Logs From 2009 to 2016.

OBJECTIVES: To assess the effect of the changing landscape of urologic residency education and training on resident operative exposure and inter-resident variability. METHODS: The Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating urology chief residents were reviewed from Academic Year (AY) 2009-2010 to 2016-2017. Cases were stratified into the 4 ACGME categories - general urology, endourology, oncology, and reconstruction. Linear regression models analyzed the association between training year, volume, and type of cases performed. Inter-resident variability in case exposure was calculated by the difference between the ACGME reported 10th and 90th percentiles. RESULTS: During the study period, the mean number of cases performed per resident was 1092 (standard deviation 32.7). Although there was no significant change in total case volume, there were changes within case categories. Endoscopic, retroperitoneal oncology, and male reconstruction case volume all increased significantly (Δ20.1%, Δ 5.1%, Δ 8.2%, respectively, all P < .05). This was balanced with a concomitant decrease in pelvic oncology and female reconstruction cases (Δ 10.0% and Δ 14.5%, respectively, both P < .05). There was a 27.8% increase in laparoscopic/robotic cases (P < .001). The ratio difference between the 10th percentile and 90th percentile ranged from a low of 2.5 for retroperitoneal oncology cases to a high of 5.2 for extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. CONCLUSION: From AY2009-2010 to 2016-2017, residency case volume has remained constant, but there has been a change in types of cases performed and proliferation of minimally invasive techniques. Significant variability of inter-resident operative experience was noted.

Applicants' Perspectives of the Urology Residency Match Process.

INTRODUCTION: Despite the competitiveness and high stakes of the urology residency match little research has focused on the application process from the applicants' perspective. METHODS: In April 2018 we e-mailed a 23-question multiple-choice survey to all applicants to the 2018 urology residency match. RESULTS: Of the 436 applicants 186 (42.7%) completed our survey. Among the most interesting findings was that most applicants (65.1%) would prefer limiting the number of applications per applicant to 60 or fewer, and the vast majority of applicants (89.8%) would prefer a system where interviews are organized by geographic region to reduce cross-country travel. Most applicants (86.6%) also prefer the January match over the National Resident Matching Program match in March. CONCLUSIONS: This study provides applicants' perspectives of the urology residency match process as well as a working framework for improving the application process at the national and individual program levels. Combining these findings with the perspective of the residency program directors should provide the optimal guidance for the structure of the match process going forward.

The current state of diversity and multicultural training in urology residency programs.

PURPOSE: The American population continues to increase in ethnic diversity. However, the medical work force has lagged behind these population trends. We evaluated the extent of diversity and perceived barriers to multicultural training in American urology programs. MATERIALS AND METHODS: A 25-question nonvalidated diversity questionnaire was distributed electronically to 112 American urology residency program directors. RESULTS: A total of 62 program directors (55%) responded, representing all American Urological Association geographic regions nationwide. Of the respondents 92% were male and 90% were older than 40 years. During their residency 44% of respondents reported no female co-residents and 51% reported no co-residents of color. As faculty, 40% of respondents reported no female colleagues and 49% reported no colleagues of color. Of the respondents 75% identified no formal process to recruit faculty of color. With regard to current residency training 36% of respondents reported 1 or fewer female residents, 66% reported at least 1 black resident and 42% reported at least 1 Hispanic resident in their program. Of the respondents 75% stated that multicultural training is important for residents and 46% reported no barriers to multicultural training. However, 75% of program directors reported no formal multicultural program training. CONCLUSIONS: Most urology program directors trained with few minority or female co-residents. This paucity of diversity has continued with current faculty members. Residents are increasingly diverse but few urology residency programs have a formal curriculum or mentors to address diversity issues. Therefore, current residency training may not encourage diversity at academic centers or adequately prepare residents to serve an increasingly diverse patient population.

Long-term followup of complete primary repair of exstrophy: the Seattle experience.

PURPOSE: Since 1989, we have used the complete primary repair of exstrophy surgical technique to reconstruct the genitourinary system of children born with the exstrophy-epispadias complex based on the assumption that this complex represents a malformation. We initially reported using this technique in 1999. We now report a longer term followup of this initial group as well as surgical outcomes in a larger group of children who have undergone this repair for classic bladder exstrophy. MATERIALS AND METHODS: Since 1989, we have prospectively followed 39 children who underwent the complete primary repair of exstrophy technique to construct classic bladder exstrophy. Median followup in the original group of patients that we reported in 1999 is 106 months. Median followup in the entire series is 58 months. RESULTS: Of boys and girls 4 years or older 74% have achieved daytime continence with volitional voiding. Of boys and girls 20% and 43%, respectively, have achieved primary urinary continence without the need for bladder neck reconstruction. An additional 18% of boys and girls achieved continence with only bladder neck injection following complete primary repair of exstrophy. Complications developed in 7 of the 39 children (18%) in the entire series. CONCLUSIONS: Urinary continence has been consistently achieved with this form of exstrophy repair. Primary continence without the need for further reconstruction is possible. The results of this patient series have caused us to modify the complete primary repair of exstrophy technique in an effort to improve the rate of primary urinary continence.

Metastatic adenocarcinoma after augmentation gastrocystoplasty.

PURPOSE: Augmentation gastrocystoplasty has been proposed as an alternative to enterocystoplasty because of potential benefits, including decreased risk of mucus production, stone formation and urinary tract infections. Although cancer has rarely been reported in this patient population, it is a well recognized potential risk of all augmentation cystoplasties. To define better the risk of malignancy associated with gastric augmentation and the appropriate surveillance protocol for these patients, we describe our experience in 2 patients with metastatic adenocarcinoma following gastrocystoplasty. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who had undergone augmentation gastrocystoplasty between 1990 and 1994. Of the 72 patients identified 2 were diagnosed with a primary malignancy arising from the augmented bladder. Charts were reviewed for medical history, clinical outcomes and pathology. RESULTS: Two patients were identified with a primary bladder malignancy after gastrocystoplasty. Both patients had metastatic disease at initial presentation. Neither patient had a history of gross hematuria, recurrent urinary tract infections or pain before initial presentation. Mean patient age at augmentation was 5.5 years. Mean age at diagnosis of malignancy was 19.5 years, with a mean time from augmentation of 14 years. CONCLUSIONS: Although the risk of bladder cancer is low after gastric augmentation, the effects may be life threatening. Therefore, we advocate routine annual surveillance with cystoscopy, bladder biopsy and upper tract imaging in all patients who have undergone augmentation gastrocystoplasty.

Surgical management of congenital ureteropelvic junction obstruction: a Pediatric Health Information System database study.

PURPOSE: Although laparoscopic pyeloplasty has gained popularity, to our knowledge no multi-institutional study has evaluated the prevalence of this approach in children. We used a multicenter database to determine trends in the treatment of congenital ureteropelvic junction obstruction. MATERIALS AND METHODS: The Pediatric Health Information System database contains data on 37 freestanding hospitals for children across the United States. We extracted data on 0 to 19-year-old patients from 2001 to 2006 with the ICD-9 diagnosis code for congenital ureteropelvic junction obstruction and the procedure code for the correction of ureteropelvic junction obstruction. We identified laparoscopic cases based on hospital charges for 1) laparoscope, 2) trocar, 3) insufflating needle or 4) insufflator and tubing. Data were then analyzed using the chi-square and Student t tests to determine management trends. RESULTS: We identified 2,353 patients, of whom 2,177 (92.5%) underwent open pyeloplasty and 176 (7.5%) underwent laparoscopic pyeloplasty. The percent of pediatric pyeloplasties performed laparoscopically increased from 2001 to 2003 (2.53% to 9.73%) and has since remained stable. Patients undergoing laparoscopic pyeloplasty were significantly older than those in the open group (age 8.2 vs 3.3 years, p <0.0001). Average hospital charges were significantly higher in the laparoscopic group than in the open group ($23,295.71 vs $16,467.49, p <0.05). There was no significant difference in terms of race, gender or length of stay. CONCLUSIONS: The percent of pediatric pyeloplasties performed laparoscopically has increased with time. However, laparoscopic pyeloplasty is associated with higher hospital charges than open surgery without a significant decrease in length of stay.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs.

BACKGROUND: With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown. OBJECTIVE: We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training. METHODS: PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed. RESULTS: In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001). CONCLUSIONS: A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Aligning institutional priorities: engaging house staff in a quality improvement and safety initiative to fulfill Clinical Learning Environment Review objectives and electronic medical record Meaningful Use requirements.

BACKGROUND: House staff quality improvement projects are often not aligned with training institution priorities. House staff are the primary users of inpatient problem lists in academic medical centers, and list maintenance has significant patient safety and financial implications. Improvement of the problem list is an important objective for hospitals with electronic health records under the Meaningful Use program. METHODS: House staff surveys were used to create an electronic problem list manager (PLM) tool enabling efficient problem list updating. Number of new problems added and house staff perceptions of the problem list were compared before and after PLM intervention. RESULTS: The PLM was used by 654 house staff after release. Surveys demonstrated increased problem list updating (P = .002; response rate 47%). Mean new problems added per day increased from 64 pre-PLM to 125 post-PLM (P < .001). CONCLUSIONS: This innovative project serves as a model for successful engagement of house staff in institutional quality and safety initiatives with tangible institutional benefits.