Gender-Based Pay Gap in Urology: A Review of the Literature and Potential Solutions.

Studies have repeatedly demonstrated salary-based gender disparities in the field of Urology. These disparities persist even when accounting for contributing factors such as years of experience, hours worked, and practice setting, suggesting that inherent gender bias exists. In addition to salary discrepancies, female urologists are also less likely to be promoted and less likely to hold leadership positions as compared to male urologists. We review the data supporting these disparities and provide tangible, evidence-based solutions for the field of Urology going forward.

Metabolic Syndrome Increases Risk of Postoperative Myocardial Infarction Following Percutaneous Nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for upper tract stone burdens greater than 2 cm. Metabolic syndrome (MetS) is a constellation of conditions (diabetes mellitus, hypertension, dyslipidemia, and obesity) and is a risk factor for nephrolithiasis. Our objective was to investigate adverse cardiovascular outcomes of PCNL in patients with comorbid MetS diagnoses. MATERIALS AND METHODS: Data from the Healthcare Cost and Utilization Project State Inpatient Database for Florida and California were used to identify PCNL patients (ICD9: 55.03, 55.04) between 2007 and 2011. Patients were categorized having 0, 1-2, or 3-4 components of MetS. Postoperative myocardial infarction (MI) and inhospital mortality rate outcomes were identified. Multivariate logistic regression was used to control for patient characteristics (age, race, and primary insurance provider) and medical comorbidities. RESULTS: PCNL was performed on 39,868 patients, of whom 17,932 (45.0%) had no MetS conditions, 19,268 (48.3%) had 1-2 MetS conditions, and 2668 (6.7%) had 3-4 MetS conditions. With increasing MetS conditions, patients had increased incidence of postoperative MI (0: 0.6%; 1-2: 1.0%; 3-4: 1.8%, p < 0.001). On multivariate analysis, the presence of 3-4 MetS comorbidities increased the odds of a postoperative MI (1-2: odds ratio [OR] 1.2, 95% confidence interval [CI] 0.94-1.53, p = 0.147; 3-4: OR 2.2, 95% CI 1.54-3.15, p < 0.001). CONCLUSIONS: MetS patients have an increased risk of MI following PCNL given their pre-existing comorbidities. Routine preoperative cardiac testing may benefit this population before PCNL.

Assessment of Patient and Surgical Variables Including Residency Training Level on Adverse Events After Ureteroscopy for Ureteral Stones: A Multivariate Analysis.

PURPOSE: With advances in technology, ureteroscopy (URS) is increasingly utilized for the management of urolithiasis. Previous studies have attempted to characterize the post-operative complication and readmission rates relative to the technical difficulty of the procedure. There is limited data exploring the resident level of training and its effect on adverse outcomes in these cases. We review our experience with URS to create a model to predict factors, including resident experience, that affect rates of post-operative complications. MATERIALS AND METHODS: We reviewed ureteroscopies performed at our academic facility from January 2009 to December 2013. Ureteral-only stones were examined for demographics, stone characteristics, operative techniques, and resident training level. Post-operative adverse events requiring urology consultation, clinic or emergency department visits, hospital admission, prolonged post-operative hospitalization, or unplanned repeat surgery within 30 days of the procedure were identified and analyzed. RESULTS: Four hundred seventeen cases of URS for ureteral-only stones were included for study. We identified 53 (12.7%) involving an unexpected post-operative course. Several logistic regression models were created to make a predictive model of adverse events. One model found only lack of stone clearance to be significant for increasing the likelihood of an adverse event. A second model determined that no residency year showed higher odds of adverse outcomes. CONCLUSIONS: URS has increased in prevalence in recent years, but overall complication rates are low. Resident level of experience does not appear to impact adverse event rate. Stone clearance during initial surgery appears to be the most important in avoiding adverse events. Further expansion of the database over time will improve our ability to predict adverse outcomes in this common procedure.

Is the robotic approach feasible for repair of iatrogenic injuries of the lower ureter?

OBJECTIVES: To analyze the robotic approach as treatment of iatrogenic ureteral injuries. METHODS: Medical records were reviewed for patients undergoing robotic-assisted laparoscopic ureteral reimplantation at the University of Missouri from 2009 to 2014. Patient charts were analyzed for demographics, prior abdominal surgeries, circumstances of injury, outcomes, and other relevant information. RESULTS: Nine patients met inclusion criteria. The average age was 44.6. Patients had an average of 4.3 abdominal surgeries. Injury occurred during hysterectomy (open, laparoscopic, or vaginal) in eight patients (88.9 %), five cases were laparoscopic, two utilized robotic assistance, and one injury occurred during uterosacral vault suspension. All cases were related to gynecological procedures. On average, ureteral injury was detected 17.2 days after the initial surgery and repaired 62.3 days after initial operation. The average surgical repair time was 295.9 min (range 168-498) with an average blood loss of 77.2 mL (range 20-150). Four patients required a psoas hitch, with one receiving both a psoas hitch and a Boari flap. Postoperatively, patients had an average hospital stay of 2.7 days. One patient had ileus for greater than 3 days, and another was readmitted within 30 days for pain control and antiemetics following stent removal. One patient underwent open reimplantation 3 years after original surgery for development of ureteral stricture. At follow-up, all patients had returned to baseline renal function. CONCLUSIONS: Robotic approach is feasible and a safe option for distal iatrogenic ureteral injuries occurring during gynecological procedures. Prior abdominal surgery or delayed repair does not preclude a robotic approach.

Survival Outcomes in Men Undergoing Radical Prostatectomy After Primary Radiation Treatment for Adenocarcinoma of the Prostate.

PURPOSE: Salvage radical prostatectomy (SRP) is a treatment modality for patients with radio-recurrent prostate cancer but is currently underutilized. We analyzed the survival outcomes in patients receiving SRP for radio-recurrent prostate cancer. The secondary outcome was effect of lymph node dissection on survival following SRP. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) 18 registry was used to identify patients that underwent radical prostatectomy between 1988 and 2010. Search identified 2628 patients with prostate cancer that underwent surgery after radiation. Following exclusion, 364 patients remained. Endpoints included overall survival (OS) and cancer-specific survival (CSS). Effect of pelvic lymph node dissection (PLND) status and number of nodes retrieved were also studied. Kaplan-Meier analysis, log-rank tests, and Cox-proportional hazard models were used, and P < .05 was considered to be significant. RESULTS: OS was 77.5% at 10 years and 37.3% at 20 years; CSS was 88.6% at 10 years and 72.7% at 20 years. The hazard of mortality was higher in men who did not undergo PLND with a hazard ratio of 1.4 for OS (P = .2) and 2.7 for CSS (P = .01). No significant increase in OS or CC was seen with increasing number of lymph nodes retrieved. Some limitations are inherent to the SEER database and include the lack of hormone manipulation status and PSA data. CONCLUSIONS: Excellent long-term survival can be achieved with SRP. PLND improves CSS but increasing nodal yield does not significantly improve survival. Small sample sizes limit the overall power of this study.