RESUMO
OBJECTIVE: To evaluate different types of failure after minimally-invasive pyeloplasty (MIP) when stratified by initial radiologic study and symptoms after ureteral stent removal. METHODS: We retrospectively reviewed adults who underwent MIP (1996-2019) at a single academic center. Patients with at least 11 months of follow-up and patients who had a Mag3 scan as their initial postoperative imaging were included. Postprocedure, patients were categorized as having normal, equivocal, or obstructed imaging based on their initial radiologic test. Patients who were obstructed were excluded. Primary outcome was procedural failure, defined as the need for a procedure to treat recurrent obstruction. Secondary outcomes were radiologic failure and symptomatic failure. Groups were compared to assess for statistical significance (P <.05). RESULTS: Overall, 122 patients met inclusion criteria. On initial postoperative imaging, 108 (89%) patients had no obstruction and 14 (11%) had equivocal findings. The procedural failure rate was 6.5% in the unobstructed group and 28.6% in the equivocal group (P = .023). Seven unobstructed patients (6.5%) and 2 equivocal patients (14.3%) eventually experienced radiologic failure (P = .275). Among patients who had no obstruction on initial imaging and remained asymptomatic, only one (0.9%) required a salvage procedure. CONCLUSION: Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians' choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be limited.
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Laparoscopia , Ureter , Obstrução Ureteral , Humanos , Adulto , Pelve Renal/diagnóstico por imagem , Pelve Renal/cirurgia , Estudos Retrospectivos , Obstrução Ureteral/diagnóstico por imagem , Obstrução Ureteral/etiologia , Rim , Ureter/diagnóstico por imagem , Ureter/cirurgia , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodos , Laparoscopia/efeitos adversosRESUMO
OBJECTIVE: To determine the utility of post-operative imaging after ureteroneocystostomy and whether long-term symptom or radiographic surveillance aided in the detection of recurrent obstruction. MATERIALS AND METHODS: Adult patients were identified who underwent a ureteroneocystostomy with or without psoas hitch or Boari flap between January 2012 and June 2021. Patients who underwent a bilateral procedure, had active malignancy or immediate failure, or did not have 6 months of follow-up with 2 imaging studies were excluded. Using the initial imaging study after stent removal, patients were categorized into normal and equivocal groups according to predefined radiologic criteria. Patients were followed longitudinally to determine whether they subsequently developed radiographic evidence of obstruction. Follow up visits were reviewed for patient symptoms suggestive of post-operative obstruction, defined as flank pain, hematuria, or pyelonephritis. RESULTS: One hundred and twelve patients met criteria. Normal and equivocal initial imaging was seen in 99 and 13 patients, respectively. At a mean radiologic follow-up of 32 months, stricture recurrence was identified in 3 patients with normal initial imaging. No patients with initial equivocal imaging demonstrated recurrent obstruction at mean radiologic follow-up of 29 months. All patients with recurrent stricture presented with symptoms of obstruction. Of patients who developed symptoms after ureteroneocystostomy, 13.6% had recurrent stricture. CONCLUSION: Asymptomatic patients after ureteroneocystostomy who had either normal or equivocal post-operative imaging did not benefit from additional radiologic testing in this cohort. All patients that demonstrated failure presented with symptomatic obstruction that warranted imaging. Surgeons may consider restricting surveillance imaging to symptomatic patients after the initial post-operative period.
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Ureter , Obstrução Ureteral , Adulto , Constrição Patológica , Cistostomia/efeitos adversos , Cistostomia/métodos , Humanos , Estudos Retrospectivos , Retalhos Cirúrgicos , Resultado do Tratamento , Ureter/patologia , Ureter/cirurgia , Obstrução Ureteral/cirurgiaRESUMO
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 (Pâ¯=â¯.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.
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COVID-19 , Internato e Residência , Urologia , COVID-19/epidemiologia , Currículo , Avaliação Educacional , HumanosRESUMO
OBJECTIVES: To evaluate patient factors associated with post-ureteroscopy opioid prescriptions, provider-level variation in opioid prescribing, and the relationship between opioid-free discharges and ED visits. METHODS: This is a retrospective analysis of a prospective cohort study of adults age 18 years and older who underwent primary ureteroscopy for urinary stones from June 2016 to September 2019 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) quality improvement initiative. Postoperative opioid prescription trends and variation among practices and surgeons were examined. Multivariable logistic regression models defined risk factors for receipt of opioid prescriptions. The association among opioid prescriptions and postoperative ED visits within 30 days of surgery was assessed among complete case and propensity matched cohorts, matched on all measured characteristics other than opioid receipt. RESULTS: 13,143 patients underwent ureteroscopy with 157 urologists across 28 practices. Post-ureteroscopy opioid prescriptions and ED visits declined (86% to 39%, P<.001; 10% to 6%, P<.001, respectively). Practice and surgeon-level opioid prescribing varied from 8% to 98%, and 0% to 98%, respectively. Patient-related factors associated with opioid receipt included male, younger age, and history of chronic pain. Procedure-related factors associated with opioid receipt included pre- and post-ureteroscopy ureteral stenting and access sheath use. An opioid-free discharge was not associated with increased odds of an ED visit (OR 0.77, 95% CI 0.62-0.95, P=.014). CONCLUSIONS: There was no increase in ED utilization among those not prescribed an opioid after ureteroscopy, suggesting their routine use may not be necessary in this setting.
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Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade , Ureteroscopia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos RetrospectivosRESUMO
BACKGROUND: In competitive residency specialties such as Urology, it has become increasingly challenging to differentiate similarly qualified applicants. Residency interviews are utilized to rank applicants, yet they are often biased and do not explicitly address ACGME core competencies. OBJECTIVE: We hypothesized a team-based exercise in the urology residency interview centered on building LEGOs assesses core competences. DESIGN: From 2014-2017, students interviewing for urology residency at two institutions participated in a LEGO™ building activity. Applicants were assigned to "architect"- describing how to construct a structure - or "builder" - constructing the same structure with pieces-using only verbal cues to assemble the structure. Participants were graded using a rubric assessing competencies of interpersonal communication, problem-based learning, professionalism, and manual dexterity (indicator of procedural skill). The total minimum score was 16 and maximum was 80. SETTING: The study took place at two tertiary referral centers: University of Michigan Medical School in Ann Arbor, MI, and University of Utah School of Medicine in Salt Lake City, UT. PARTICIPANTS: A total of 176 applicants participated, comprised of applicants interviewing for urology residency at two institutions during the study timeframe. RESULTS: For architects and builders, there was a maximum score of 80, and minimum of 34 and 32, respectively. Both distributions show a right shift with mean scores of 64.3 and 65.9, and median scores of 69 and 65.5. Successful pairs excelled with consistent nomenclature and clear directionality. Ineffective pairs miscommunicated with false affirmations, inconsistent nomenclature, and lack of patience. CONCLUSIONS: The LEGO™ exercise allowed for standardized assessment of applicants based on ACGME core competencies. The rubric identified poor performers who do not rise to the challenge of a team-based task.
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Internato e Residência , Urologia , Comunicação , Exercício Físico , Humanos , Profissionalismo , Urologia/educaçãoRESUMO
PURPOSE: The Society for Improving Medical Professional Learning (SIMPL) app is an innovative, convenient and validated smartphone-based tool to evaluate residents' operative performance. In this study, we describe the initial implementation of SIMPL in our program's pediatric urology rotation-the first among urology residencies-and provide preliminary data on its adoption by residents and faculty. MATERIALS AND METHODS: Residents and faculty in our pediatric urology division submitted SIMPL evaluations following surgical cases from August 2019 to July 2020. Evaluations consisted of ratings in 3 domains: resident autonomy, resident operative performance and patient-related case complexity. An online survey was also used to gauge attitudes towards SIMPL, describe patterns of use and solicit feedback on areas for improvement. RESULTS: Eight residents and 6 faculty submitted 141 evaluations, with 76.6% of evaluated cases having both faculty and resident ratings. Verbal feedback was included in 94.2%. Faculty-resident agreement ranged from 68.6% to 75.2% (kappa=0.47 to 0.61). Faculty rated postgraduate year (PGY)-4 residents as more autonomous (p=0.040) and higher performing (p=0.028) than PGY-3 residents. All participants agreed that SIMPL was easy to use and compared favorably to existing avenues of feedback. Barriers to implementation included lack of reminders for evaluations and evaluation fatigue. CONCLUSIONS: The SIMPL application improved both frequency and quality of resident operative feedback. Among participants, SIMPL was preferred over the existing feedback system at our institution.
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Feedback Formativo , Internato e Residência/métodos , Aplicativos Móveis , Procedimentos Cirúrgicos Urológicos/educação , Urologia/educação , Competência Clínica/estatística & dados numéricos , Docentes/estatística & dados numéricos , Estudos de Viabilidade , Humanos , Internato e Residência/estatística & dados numéricos , Pediatria/educação , Projetos Piloto , Reprodutibilidade dos Testes , Smartphone , Urologistas/educação , Urologistas/estatística & dados numéricosRESUMO
PURPOSE: Ureteral stents are commonly placed after ureteroscopy. Although studies indicate that stents are associated with patient discomfort, their impact on downstream health services use is unclear. We examined patterns of stent utilization in Michigan and their association with unplanned health care encounters. MATERIALS AND METHODS: We used the Michigan Urological Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) clinical registry to identify ureteroscopy cases between 2016 and 2019. Factors associated with stent placement were examined using bivariate and multivariable statistics. Using multivariable logistic regression, we evaluated whether stent placement was associated with emergency department visits and hospitalizations within 30 days. RESULTS: We identified 9,662 ureteroscopies and a stent was placed in 7,025 (73%) of these. Frequency of stent use across the 137 urologists varied (11%-100%, p <0.001) and was not associated with total case volume. Factors associated with stent use included age and stone size. Pre-stented cases and renal stones had a decreased odds of stent placement. On multivariable analysis after adjusting for risk factors, stent placement was associated with a 1.25 higher odds of emergency department visit (OR 1.25, 95% CI 1.01-1.54, p=0.043) but not hospitalization (OR 1.28, 95% CI 0.94-1.76, p=0.12). In a single high volume practice, 0.5% of cases that omitted a stent required urgent stenting postoperatively. CONCLUSIONS: There is substantial variation in the use of stents in Michigan, irrespective of case volume. Stent placement significantly increased the odds of an emergency department visit after surgery. Importantly, stent omission rarely required subsequent urgent stent placement.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cálculos Renais/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents , Ureter/cirurgia , Ureteroscopia , Adulto , Idoso , Feminino , Humanos , Masculino , Michigan , Pessoa de Meia-IdadeRESUMO
Introduction: Characterizing patterns of laser activation is important for assessing thermal dose during laser lithotripsy. The objective of this study was twofold: first, to quantify the range of operator duty cycle (ODC) and pedal activation time during clinical laser lithotripsy procedures, and second, to determine thermal dose in an in vitro caliceal model when 1200 J of energy was applied with different patterns of 50% ODC for 60 seconds. Methods: Data from laser logs of ureteroscopy cases performed over a 3-month period were used to calculate ODC (lasing time/lithotripsy time). Temporal and rolling 1-minute average power tracings were generated for each case. In vitro experiments were conducted using a 21 mm diameter glass bulb in a 37°C water bath, simulating a renal calix. A LithoVue ureteroscope with attached thermocouple was inserted and 8 mL/min irrigation was delivered with a 242 µm laser fiber within the working channel. In total, 1200 J of laser energy was applied in five different patterns at 20 W average power for 60 seconds. Thermal dose was calculated using the Sapareto and Dewey t43 method. Results: A total of 63 clinical cases were included in the analysis. Mean ODC was 32% overall and 63% during the 1-minute of greatest energy delivery. Mean time of pedal activation was 3.6 seconds. In vitro studies revealed longer pedal activation times produced higher peak temperature and thermal dose. Thermal injury threshold was reached in 9 seconds when 40 W was applied at 50% ODC with laser activation patterns of 30 seconds on/off and 15 seconds on/off. Conclusion: ODC was quantified from clinical laser lithotripsy cases: 32% overall and 63% during 1-minute of peak power. Time of pedal activation is an important factor contributing to fluid heating and thermal dose. Awareness of these concepts is necessary to reduce risk of thermal injury during laser lithotripsy procedures.
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Lasers de Estado Sólido , Litotripsia a Laser , Humanos , Cálices Renais , Temperatura , Ureteroscopia/efeitos adversosRESUMO
OBJECTIVE: Research suggests recently graduated urology residents do not feel ready for independent practice. We conducted a study to determine if Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements, resident case logs, and graduating resident perceived readiness for practice are aligned with the procedural demand and needs of the current urology workforce. DESIGN: Correlative study comparing the association between (1) workforce demand and ACGME case requirements, and (2) workforce demand and perceived resident competency. Three distinct datasets were used; (1) the 2017 Medicare Part B National Summary Data File; (2) the 2017 National Data Report published by the ACGME; and (3) a graduating resident survey from Okhunov et al. SETTING: N/A. PARTICIPANTS: N/A. RESULTS: In 2017, there were a total of 6,784,696 urologic cases performed through Medicare. We found nonsignificant positive associations between resident case logs (rhoâ¯=â¯0.16, pâ¯=â¯0.5784), ACGME minimum procedure requirements (rhoâ¯=â¯0.42, pâ¯=â¯0.1255), and Medicare procedural demand. Our 15 index procedures accounted for 21.1% (nâ¯=â¯1,431,775) of all Medicare cases, with a median number of 7706 procedures. Endopyelotomy was the least common procedure (nâ¯=â¯98), while cystoscopy was the most common (nâ¯=â¯980,623). Medicare case volume was positively correlated with graduating residents' procedural confidence (râ¯=â¯0.86, p < 0.0001). We identified four categories with varied alignment of training and demand: (1) high volume and high confidence, (2) high volume and low confidence, (3) low volume and high confidence, and (4) low volume and low confidence. CONCLUSIONS: Optimizing urology residency training is time-sensitive and important. Using national Medicare data coupled with recently graduated urology resident survey results, we provide a guiding framework for improving the alignment of training with workforce demand. Informed by these results, we recommend altering training requirements to reflect these needs.
Assuntos
Internato e Residência , Urologia , Acreditação , Idoso , Competência Clínica , Educação de Pós-Graduação em Medicina , Humanos , Medicare , Estados Unidos , Urologia/educação , Recursos HumanosRESUMO
Introduction: As many as 12.5% of patients who undergo ureteral stent placement fail to have their stent removed in a timely manner. Because retained stents can be a source of substantial morbidity, there is a need for solutions to help urologists track their stented patients. Materials and Methods: We developed a cloud-based software that is agnostic to the device manufacturer and can be seamlessly integrated into the electronic health record (EHR). The software automatically registers patients who undergo ureteral stent placement and then follows them through their postoperative course to ensure timely follow-up for device removal. To validate our software's performance, we reviewed the medical records of patients who underwent stent placement for any indication at our institution between February 1, 2018, and February 28, 2018. Results: During our 1-month pilot study, a total of 51 ureteral stents were placed during 49 procedures that were performed on 46 patients. Our software effectively captured all of these procedures. It was able to properly distinguish 31 procedures where the patient who underwent stenting had follow-up scheduled before surgery. More importantly, it alerted our schedulers to 18 procedures for which no return visit had been scheduled. Furthermore, our software was able to register follow-up attendance, correctly identifying 10 procedures where patients failed to arrive. Conclusion: We describe a high-fidelity software solution for automated tracking of ureteral stents that is agnostic to the device manufacturer and can be seamlessly integrated into the EHR, causing minimal disruption to provider workflows.
Assuntos
Ureter , Obstrução Ureteral , Computação em Nuvem , Humanos , Projetos Piloto , Software , Stents , Ureter/cirurgiaRESUMO
The use of robotic surgery in urology has grown exponentially in the past 2 decades, but robotic surgery training has lagged behind. Most graduating residents report a lack of comfort independently performing common robotic urologic surgeries, despite an abundance of available resources. There is a general consensus on the key components of a comprehensive robotics curriculum, and well-validated tools have been developed to assess trainee competency. However, no single curriculum has emerged as the gold standard on which individual programs can build their own robotics curricula.
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Educação de Pós-Graduação em Medicina/tendências , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Urológicos/educação , Urologia/educação , Competência Clínica , Currículo/normas , Currículo/tendências , Previsões , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Procedimentos Cirúrgicos Robóticos/normas , Procedimentos Cirúrgicos Robóticos/tendências , Procedimentos Cirúrgicos Urológicos/normas , Procedimentos Cirúrgicos Urológicos/tendências , Urologia/normas , Urologia/tendênciasRESUMO
OBJECTIVES: Empirically dosed enoxaparin is routinely given in the postoperative period for venous thromboembolism (VTE) prophylaxis after radical cystectomy (RC). Patient-specific factors may alter its pharmacokinetics, and it is unclear whether this leads to levels sufficient for antithrombosis. We sought to evaluate variability of anti-factor Xa levels in a cohort of RC patients receiving perioperative enoxaparin prophylaxis. MATERIAL AND METHODS: Patients undergoing RC at a single institution were placed on a postoperative pathway that included enoxaparin. An anti-factor Xa level was drawn 2 to 4 hours after the third dose. The target range for prophylaxis was 0.3 IU/ml to 0.5 IU/ml. RESULTS: The primary outcome was anti-factor Xa level. Demographics, operative time, hospital course, and 30-days post-operative VTE were compared by anti-factor Xa level group using univariate and multivariable analyses. Between January 2018 and 2019, 107 RC patients remained on pathway and were included in our analysis. Sixty-five (61%) were below target range for VTE prophylaxis. A single VTE event (0.9%) occurred in a subprophylactic individual. The subprophylactic group had a significantly higher body mass index (P < 0.01) than those within target range. CONCLUSIONS: Higher body mass index was associated with subprophylactic enoxaparin dosing after RC. Nearly two-thirds of patients had below target anti-factor Xa levels. This suggests that dosing could be further individualized, but given the low incidence of VTE, implications of dose-adjusted prophylaxis on VTE prevention remain unknown.
Assuntos
Anticoagulantes/administração & dosagem , Cistectomia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Neoplasias da Bexiga Urinária/terapia , Tromboembolia Venosa/prevenção & controle , Idoso , Anticoagulantes/farmacocinética , Variação Biológica da População , Índice de Massa Corporal , Quimioterapia Adjuvante/estatística & dados numéricos , Relação Dose-Resposta a Droga , Cálculos da Dosagem de Medicamento , Monitoramento de Medicamentos/estatística & dados numéricos , Enoxaparina/administração & dosagem , Enoxaparina/farmacocinética , Feminino , Heparina/sangue , Humanos , Incidência , Masculino , Terapia Neoadjuvante/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologiaRESUMO
Aim: We sought to compare the outcomes of patients who underwent an open vs robotic ureteroneocystostomy for ureteral obstruction. Methods: Retrospective review was performed on adult patients who underwent primary ureteroneocystostomy for obstruction from January 2012 to April 2018. Intraoperative outcomes of estimated blood loss (EBL) and operative time, as well as postoperative outcomes of catheter and stent duration, length of hospital stay, inpatient nurse-controlled opioid use, patient-controlled analgesia (PCA), and outpatient opioid prescription, complications, readmission, radiologic and clinical stricture recurrence, and follow-up, were compared. Among the open cohort, indications for an open approach were evaluated, identifying patients with prior complex open abdominal surgery that would make an open approach preferable. Results: Open ureteroneocystostomy was performed in 27 patients compared with 18 who underwent a robotic approach. The open and robotic cohorts were not significantly different in age, gender, Charlson comorbidity index, stricture location or side, abdominal surgery (laparoscopic or open), pelvic radiation, or preoperative urinary tract infection. The robotic group had a significantly lower rate of prior open abdominal surgery. The robotic cohort had significantly lower EBL, length of stay (LOS), catheter duration, prescribed morphine milliequivalents (MME) at discharge, and rate of PCA usage. Among the open cohort, 13 (48%) patients demonstrated indications making an open approach preferable. Comparing the robotic group with the remaining 14 open patients revealed a significantly lower rate of inpatient PCA use, prescribed MME at discharge, LOS, and catheter duration. Mean operative time was higher in the robotic group. EBL was not significantly different in this subanalysis. Conclusions: Robotic ureteroneocystostomy provides similar outcomes when compared with an open approach in well-selected patients when assessing for recurrent ureteral obstruction or adverse events. Robotic surgery is associated with lower postoperative narcotic pain prescriptions at discharge, lower PCA usage, and shorter LOS, which are important benefits when compared with open surgery.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Ureter , Obstrução Ureteral , Adulto , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Ureter/cirurgia , Obstrução Ureteral/cirurgiaRESUMO
INTRODUCTION: The 2019-2020 coronavirus pandemic has had a significant impact on all aspects of health care. Decrease in clinical and operative volume and limitations for conferences has drastically decreased educational opportunities for resident trainees. We describe the formation and initial success of the Collaborative Online Video Didactics lecture series, a multi-institutional online video didactics collaboration. METHODS: Zoom data extraction and postlecture evaluation surveys were used to collect data on the impact of the pandemic on local educational activities as well as feedback about the lecture series. Lectures are being given by faculty from 35 institutions. The twice daily, hour-long webinar averages more than 470 live viewers per session with an average of 33.5 questions per session and has over 7,000 YouTube views of the recordings after the first 2 weeks. RESULTS: Viewers reported significant decreases in outpatient (75.2%), inpatient (64.9%) and operating room (77.7%) volumes at local programs, and only half (52.7%) of the survey responders indicated an increase in didactics locally. The lectures have been well-received, with over 90% of respondents giving the lecturers and series above average or excellent ratings. A significant majority of responders indicated that the lecture series has allowed for ongoing education opportunities during the pandemic (95.0%), helped to access faculty experts from other institutions (92.3%) and provided a sense of community connectedness during this period of social isolation (81.7%). CONCLUSIONS: We strongly encourage other institutions and trainees to participate in the didactic series and hope that this series can continue to evolve and be of benefit beyond the pandemic.
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OBJECTIVE: To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days). METHODS: A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups. RESULTS: Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001). CONCLUSION: In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.
Assuntos
Cistostomia , Complicações Intraoperatórias/cirurgia , Ureter/lesões , Ureter/cirurgia , Ureterostomia , Adulto , Cistostomia/métodos , Intervenção Médica Precoce , Feminino , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Ureterostomia/métodosRESUMO
Objective: To understand how time to stent placement impacts outcomes in patients with obstructing ureteral stones and concern for infection. Materials and Methods: Using a prospective urology consult institutional database (2011-2016), we identified patients who presented to the emergency department (ED) with an obstructing ureteral stone, met two or more systemic inflammatory response syndrome (SIRS) criteria (temperature [T] >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute, white blood cell count >12 k/µL or <4 k/µ), and underwent stent placement. The primary outcome of interest was impact of stent timing on intensity of care (need for intensive care unit [ICU]) as well as overall length of stay (LOS). Results: Forty-eight patients were identified who met the study criteria. Overall, 58.3% had positive urine cultures. There was no difference between groups with across a range of clinical variables. While the need for ICU admission did not differ between groups, those patients who had a ureteral stent placed within 6 and 10 hours of ED arrival had a significantly decreased LOS (35.6 hours vs 71.6 hours, p = 0.01; 45.7 hours vs 82.4 hours, p = 0.04) relative to those patients who were stented outside these intervals. Conclusion: In patients with an obstructing ureteral calculus and concern for infection, there is a beneficial effect to timelier stent placement in the form of decreased overall LOS.
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Infecções Relacionadas à Prótese/etiologia , Stents/efeitos adversos , Ureter/cirurgia , Cálculos Ureterais/cirurgia , Obstrução Ureteral/cirurgia , Adulto , Cuidados Críticos , Serviço Hospitalar de Emergência , Feminino , Frequência Cardíaca , Humanos , Inflamação , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Cálculos Ureterais/complicações , Obstrução Ureteral/complicaçõesRESUMO
Five percent of urothelial carcinoma occurs in the upper urinary tract (UUT), a challenging location to biopsy. We aim to evaluate concordance between biopsy, cytology, and resection specimens in a large upper tract urothelial carcinoma (UTUC) cohort. One hundred seventeen UTUC resections with UUT biopsy and/or cytology specimens from 2000 to 2016 were retrieved; pathologic material was re-reviewed, evaluated for concordance, and correlated with clinical information. Fourteen percent of preoperative biopsies, including 8 from the renal pelvis and 6 from the ureter, lacked neoplastic diagnoses. Seventy-seven percent of diagnostic biopsies included subepithelial tissue; 11% demonstrated reclassification of grade and 30% demonstrated reclassification of invasion status. Twenty-six percent of renal pelvis UTUC and 36% of ureter UTUC were invasive only on resection. Of 18 UTUCs reclassified from noninvasive high-grade papillary urothelial carcinoma to invasive high-grade papillary urothelial carcinoma, 39% had prior radical cystectomy (versus 8% invasive UTUC and 11% noninvasive UTUC with concordant biopsies). Most high-grade UTUC (88%) and some low-grade UTUC (58%) resections had abnormal cytology results. Biopsy-resection pairs with concordant invasion status and pairs with discordant invasion status showed similar rates of recurrence (38% versus 38%) and metastasis (25% versus 27%). Fourteen percent of UUT biopsies lacked diagnostic neoplastic material. Grade concordance between biopsy and resection was high (89%), but 30% of cases showed invasion only on resection. Subepithelial tissue was less commonly present in ureter biopsies, particularly from the midureter or proximal ureter. UTUC in patients with prior cystectomy were more likely to show invasion on resection but not biopsy.
Assuntos
Carcinoma de Células de Transição/patologia , Neoplasias Renais/patologia , Neoplasias Ureterais/patologia , Sistema Urinário/patologia , Urotélio/patologia , Idoso , Idoso de 80 Anos ou mais , Biópsia , Citodiagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Estudos RetrospectivosRESUMO
OBJECTIVE: To better understand today's urology applicant. METHODS: All 2016 Urology Residency Match applicants to the study-participating institutions were provided a survey via email inquiring about their paths to urology, their career aspirations, how they evaluate a training program, and how they perceive residency programs evaluate them. RESULTS: Of a possible 468 applicants registered for the match, 346 applicants completed the survey. Only 8.7% had a mandatory urology rotation, yet 58.4% believed that a mandatory urology rotation would influence their career decision. Most applicants (62.1%) spent more than 8 weeks on urology rotations, and 79.2% completed 2 or more away rotations. Applicants were attracted to urology by the diversity of procedures, prior exposure to the field, and the mix of medicine and surgery, with mean importance scores of 4.70, 4.52, and 4.45 of 5, respectively. Female applicants were more likely to be interested in pediatric urology, trauma or reconstructive urology, and female pelvic medicine and reconstructive surgery. Significant differences in survey results were noted when applicants were separated by gender. Three-fourths of respondents (75.7%) applied to more than 50 residency programs. Applicants ranked operative experience, interactions with current residents, and relationships between faculty and residents as the most important criteria when evaluating training programs. Of the subspecialties, 62.1% of applicants expressed most interest in urologic oncology. At this stage in their career, a significant majority (83.5%) expressed interest in becoming academic faculty. CONCLUSION: This study provides new information that facilitates a more comprehensive understanding of today's urology applicants.