Program Directors' Perspectives on Residency Applications in the Post‒United States Medical Licensing Examination Step 1 Era: A Case for Standardized Letters of Recommendation?

INTRODUCTION: The United States Medical Licensing Examination (USMLE) Step 1 test evolved into a key metric utilized by program directors (PDs) in assessing candidates for residency. The transition to a USMLE Step 1 binary pass/fail scoring system has resulted in a loss of an important objective assessment. With national movements toward pass/fail systems for clerkship grading and trends toward abandonment of class ranking, assessing residency applications has become increasingly challenging. METHODS: The Society of Academic Urologists convened a task force to, in part, assess the perspectives of urology PDs regarding the importance of various aspects of a residency application for predicting clinical performance. An anonymous survey was disseminated to all urology PDs in the US. Perspectives on 11 potential application predictors of clinical performance and demographics were recorded. Descriptive statistics characterized PD responses. Friedman test and pairwise Wilcoxon tests were used to evaluate the relative ranks assigned to application elements by PDs. RESULTS: There was a 60.5% response rate (89/147). Letters of recommendation (LORs) were ranked as the most important predictor, with a mean rank of 2.39, median of 2 (IQR 1-3). Clerkship grades and USMLE Step 1 were comparable and ranked second. Medical school reputation ranked the lowest. There was significant subjective heterogeneity among categories; however, this was less so for LORs, which predominated as the most important factor among application elements (P < .001). CONCLUSIONS: To our knowledge, this is the largest sample size assessing PD perspectives on application factors that predict clinical performance. The second (clerkship grades) and third (USLME Step 1) most important factors moving toward binary pass/fail systems create an opportunity for actionable change to improve assessment objectivity. Our data demonstrate LORs to be the most important factor of residency applications, making a compelling argument for moving toward a standardized LOR to maximize this tool, mitigate bias, and improve interreviewer reliability.

Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

Characterizing the biofilm of artificial urinary sphincters (AUS).

Background: There is a paucity of data regarding the bacterial colonization on artificial urinary sphincter (AUS) devices following revision surgery. We aim to evaluate the microbial compositions of explanted AUS devices identified on standard culture at our institution. Methods: Twenty-three AUS devices explanted were included in this study. During revision surgery, aerobic and anaerobic culture swabs are taken from the implant, capsule, fluid surrounding the device, and biofilm, if present. Culture specimens are sent to the hospital laboratory for routine culture evaluation immediately upon case completion. Differences in number of microorganism species detected across samples (richness) against demographic variables were determined through backwards selection of all variables using analysis of variance (ANOVA). We assessed the prevalence (how many times each species occurred) of microbial culture species. Statistical analyses were performed using the statistical package in R (version 4.2.1). Results: Cultures reported positive results in 20 (87%) cases. Coagulase-negative staphylococci were the most commonly identified bacteria among explanted AUS devices (n=16, 80%). Among two of the four infected/eroded implants, more virulent organisms such as Escherichia coli and fungal species such as Candida albicans were identified. The mean number of species identified amongst culture positive devices was 2.15±0.49. The number of unique bacteria identified per sample was not significantly associated with demographic variables including race, ethnicity, age at revision, smoking history, duration of implantation, etiology for explantation, and concomitant medical comorbidities. Conclusions: The majority of AUS devices removed for non-infectious reasons harbor organisms on traditional culture at the time of explantation. The most commonly identified bacteria in this setting is coagulase-negative staphylococci, which may be a result of bacterial colonization introduced at the time of implant. Conversely, infected implants may harbor microorganisms with higher virulence including fungal elements. Bacterial colonization or biofilm formation on implants may not necessarily equate to clinically infected devices. Future studies with more sophisticated technology, such as next-generation sequencing or extended cultures, may evaluate microbial compositions of biofilm at a more granular level to understand its role in device infections.

Gender Diversity in Urology Residency Program Leadership Is Associated With Gender Diversity in Residency Cohort.

OBJECTIVE: To evaluate the association of program director (PD) gender on the proportion of female residents in urology residency programs. METHODS: Demographics for program faculty and current residents matched in the 2017-2022 cycles at United States' accredited urology residency programs were collected from institutional websites. Data verification was completed using the American Urological Association's (AUA) list of accredited programs and the programs' official social media channels. Proportion of female residents across cohorts was compared using two-tailed Student's t-tests. RESULTS: One hundred forty-three accredited programs were studied, and 6 were excluded for lack of data. Thirty (22%) of the 137 programs studied have female PDs. Of 1799 residents, 571 (32%) are women. There has been an upward trend in the proportion of females matched from 26% in 2018 to 30% in 2019, 33% in 2020, 32% in 2021, to 38% in 2022. When compared to programs with male PDs, those with female PDs had a significantly higher proportion of female residents (36.2% vs 28.8%, p = .02). CONCLUSION: Nearly one-quarter of urology residency PDs are female, and approximately one-third of current urology residents are women, a proportion that has been increasing. Programs with female PDs are more likely to match female residents, whether those programs with female leadership rank female applicants more favorably or female applicants rank those programs higher. Given the ongoing gender disparities in urology, these findings indicate notable benefit in supporting female urologists in academic leadership positions.

Urinary undiversion by conversion of the incontinent ileovesicostomy to augmentation ileocystoplasty in spinal cord injured patients.

Context: Spinal cord injury (SCI) patients with neurogenic bladder and the inability to self-catheterize may require incontinent diversion to provide low-pressure drainage while avoiding the use of indwelling catheters. We demonstrate that in patients with significant functional improvement, the ileovesicostomy can be a reversible form of diversion, with simultaneous bladder augmentation using the same segment of ileum utilized for the ileovesicostomy. Multidisciplinary management should be utilized to assure mastery of intermittent catheterization before urinary undiversion. This technique allows for transition to a regimen of intermittent self-catheterization with excellent functional and urodynamic outcomes.Design: Case Series.Setting: Tertiary care hospital, Philadelphia, Pennsylvania.Participants: Three individuals with an SCI.Interventions: Conversion of bladder management from an incontinent ileovesicostomy to an augmentation ileocystoplasty, with intermittent catheterization.Outcome Measures: Ability to regain urinary continence with preservation of renal function as determined by serum creatinine and renal ultrasound.Results: Three SCI patients who had an incontinent ileovesicostomy developed sufficient functional improvement to intermittently self-catheterize reliably and underwent conversion of ileovesicostomy to ileocystoplasty. For each, the ileovesicostomy channel was taken down and detubularized, then used to create an ileal patch for augmentation ileocystoplasty. Intermittent catheterization was then used for periodic bladder drainage. All achieved large capacity, low-pressure bladders with complete continence and stable creatinine.Conclusion: In motivated SCI patients, it is possible to regain continence by converting the ileovesicostomy into augmentation ileocystoplasty, avoiding the disadvantages of a urostomy. A multidisciplinary collaborative approach facilitates the optimal rehabilitation of SCI individuals.

Holmium Laser Enucleation of the Prostate Following Previous Prostatic Urethral Lift.

Purpose: To determine the feasibility and operative challenges of holmium laser enucleation of the prostate (HoLEP) in patients with previous prostatic urethral lift (PUL) procedure. Materials and Methods: A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2021. Seven hundred ninety-three consecutive HoLEP cases were identified. Data collected included demographics, the time elapsed since previous PUL, number of PUL implants, preoperative prostate size, intraoperative complications/challenges, and postoperative follow-up. Results: Twenty-two men with a mean preoperative prostate size of 90 g (range 32-180 g) underwent HoLEP at a median of 14.4 months (range 2.8-48) after PUL. 63.6% (14/22) of cases involved prostates with preoperative sizes ≥80 g. Three cases involved PUL implant jamming of morcellator blades, which required replacing the blades. Fifteen cases (68.2%) required using a grasper or a basket device to remove free PUL implants or adenoma parts with PUL implants embedded in them. One patient needed a second procedure to remove a relatively large piece of calcified adenoma. Nonpost-PUL HoLEP was more time efficient than post-PUL HoLEP (0.77 vs 0.55 mL/minute respectively). There was no difference in functional outcome between post-PUL and nonpost-PUL HoLEP cases. Conclusions: While HoLEP can be performed safely and effectively in the PUL failure population, unique challenges arise. PUL implants may distort prostate anatomy, jam morcellator blades, and may be encountered in aberrant locations. Patients with borderline indications for PUL should be aware of the possibility of performing HoLEP in case of PUL failure.

Conversion of Holmium Laser Enucleation of Prostate to Open Prostatectomy.

OBJECTIVE: To determine the incidence and predictive factors for conversion to an open procedure during Holmium Laser Enucleation of Prostate (HoLEP). METHODS: A retrospective review was performed on files of all patients that underwent HoLEP at our institution between 2013 and 2020. Data collected included demographics, pre-operative estimated prostate size, intraoperative data, pathologic data, and functional baseline. A univariate and multivariate comparison between the pre-operative data of converted and un-converted cases was conducted. RESULTS: Among a total of 807 HoLEP procedure performed during the above period, 20 cases were converted to open procedures (2.4%). Median pre-operative estimated prostate size in cases of conversion was 228ml compared to 95ml for unconverted cases (P <.001). The reasons for conversion were anatomical in 8 cases (40%), bleeding that was difficult to control endoscopically in 4 cases (20%), expected procedure to be too long due to large prostate size in 6 cases (30%), one case of morcellation technical malfunction, and one case with very large bladder stones not suitable for endoscopic treatment. Prostate size was the only factor that was found to be associated with conversion in univariate and multivariate analysis. CONCLUSION: The risk of conversion of HoLEP to open procedures is size-dependent. The risk for conversion to open prostatectomy/cystotomy must be communicated to patients who choose HoLEP to improve the informed consent process and provide the highest quality of patient care and transparency. Open prostatectomy/cystotomy should be a part of the armamentarium of every HoLEP surgeon operating on large prostates.

Management of neurogenic detrusor overactivity.

INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD) refers to altered function of the urinary bladder, bladder outlet, and external urinary sphincter related to a confirmed neurologic disorder. Neurogenic detrusor overactivity (NDO) is a subset of NLUTD that frequently results in incontinence and may be associated with elevated bladder storage and voiding pressures resulting in upper urinary tract damage. MATERIALS AND METHODS: This article provides an update on the evaluation and management of patients with NDO. Basic bladder physiology as well as classification of NLUTD, initial urologic evaluation, and management options ranging from the most conservative to surgical interventions will be covered. RESULTS: NDO may be managed by conservative, pharmacologic, and surgical methods. Untreated or inadequately managed NDO may result in significant urologic morbidity and mortality, making careful evaluation and lifelong management necessary to optimize quality of life and prevent secondary complications. CONCLUSIONS: Patients with NDO should have life-long urologic surveillance and follow up. The extent of regular evaluation and testing should be based on the principal of risk stratification. Treatment for NDO should be considered not only for clinical symptoms such as incontinence, but also aimed at preserving renal function.

Management of urinary incontinence following treatment of prostate disease.

INTRODUCTION Men who undergo treatment for prostate disease are at increased risk of urinary incontinence (UI). UI has a known negative impact on patient quality of life. Once a thorough evaluation has been performed, there are effective modalities for treatment that can be tailored to the patient. MATERIALS AND METHODS: This review article provides the most recent evidence-based work up and management for men with incontinence after prostate treatment (IPT). Etiology, prophylactic measures, work up, surgical treatments, and patient considerations will be covered. The more recent adjustable balloon device is included in this publication as well as more traditional treatments like the artificial urinary sphincter (AUS) and male urethral sling. RESULTS: IPT can result from treatment of either benign or malignant prostate disease whether surgery or radiotherapy are utilized. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), or mixed urinary incontinence (MUI) are all possibilities. SUI after radical prostatectomy (RP) is the most common form of IPT. Patient education and implementation of pelvic therapy as well as modern surgical techniques have greatly improved continence results. AUS remains the gold standard of SUI treatment with the broadest category of patient eligibility. Patients experiencing UUI should be treated according to the overactive bladder guidelines. CONCLUSIONS: For men with IPT, it is crucial to first take a thorough patient history and delineate the exact nature of UI symptoms which will determine the options for management. Patient factors and preferences must also be taken into consideration when ultimately choosing the appropriate intervention.

How I Do It: PureWick female external catheter: a non-invasive urine management system for incontinent women.

Catheter associated urinary tract infections (CAUTIs) are common hospital-acquired infections and remain a significant medical and financial challenge to the healthcare system. Despite this risk, incontinent women may require prolonged catheterization to accurately monitor urine output and prevent skin breakdown. The PureWick Female External Urinary Catheter is a promising non-invasive urine collection system for use in incontinent women that may help reduce CAUTI rates, maintain skin integrity, accurately quantify urine output, and avoid extra healthcare costs.

Attitude is everything: keep probe pitch neutral during side-fire prostate biopsy. A simulator study.

OBJECTIVES: To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) false-negatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. PARTICIPANTS AND METHODS: Using a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirty-four trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm. RESULTS: All results are reported as mean ± sd. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 ± 4.1° and 8.0 ± 2.7 mm, respectively, and after mastering the technique decreased to 4.5 ± 2.7° (P = 0.001) and 4.5 ± 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1° increase in mean absolute pitch. Participants achieved mastery after practising 3.9 ± 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 ± 102 s) and mastery (283 ± 101 s; P = 0.39). CONCLUSION: A pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.

Female Representation at High-profile Urology Conferences, 2014-2019: A Leadership Metric.

OBJECTIVE: To measure female leadership through speakership at urology conferences and compare involvement to the overall representation of women in the urologic workforce. METHODS: A cross-sectional analysis was conducted to identify the gender of conference speakers from 2014 to 2019. Six high-profile urology conferences were selected: AUA; SUFU; SPU; SUO; GURS; WCE. Using programming published by each society, the number of invited female speakers at each conference was recorded. Comparisons were made to the proportion of practicing female urologists based on AUA census data. RESULTS: A total of 34 conferences were reviewed. From 2014 to 2019, the percentage of female representation increased from 13.7% to 19.3% (P < .05). The proportion of female speakers at all conferences ranged from 0% to 35.6%. The average absolute increase was 1.3% each year. Female representation at urology conferences in 2019 was significantly greater than female representation in the field (19.3% vs 9.9%, P < .05). CONCLUSION: There is a slight trend of increasing proportion of invited female speakers at academic urology conferences from 2014 to 2019. Although the proportion of women in urology remains low, the trend indicates that the mean proportion of female speakers is higher than the proportion of women in the field. Inclusion of female conference speakers presents an opportunity for increased gender parity within urology leadership.

Next-generation DNA sequencing for infected genitourinary implants: How I do it.

Infection of artificial urinary sphincters or inflatable penile prostheses is one of the most devastating complications after prosthetic surgery and can have a significant impact on a quality of life. Patients undergoing revision surgery with or without device replacement may have increased risk for infection when compared to initial primary surgery. As such, surgeons may utilize traditional culture results to direct antimicrobial therapy for these patients. Unfortunately, culture results can be inconclusive in up to one-third of the time even in the setting of active device infection. Next-generation sequencing (NGS) of DNA is an emerging technology capable of sequencing entire bacterial genomes and has the potential to identify microbial composition in explanted devices. Herein, we describe our institutional experience on NGS utilization in patients with genitourinary prostheses. We also highlight our methods and techniques to inform readers on the potential practices that can enhance the utility and diagnostic yield of this new and upcoming technology.

Faculty Development: How Do We Encourage Faculty to Become Better Teachers and Mentors?

PURPOSE OF REVIEW: A healthy mentor relationship is a mutually beneficial experience and a necessary part of the natural progression of a career in academic medicine. We sought to explore the advantages of and challenges to becoming a mentor in current academic urology. RECENT FINDINGS: Mentorship can promote self-confidence in the ability to choose a career, drive academic productivity, and even inspire a career in academic medicine. It is necessary to help promote advancement in diverse socioeconomic groups within medical trainees. Strong mentors can serve as role models to the next generation of doctors. However, the ability to be an effective mentor is being challenged in today's world of academic medicine. By staying current with the issues surrounding mentorship, an individual can be fulfilled and successful in training and guiding doctors into the new era of medicine.

Iatrogenic bladder rupture in individuals with disability related to spinal cord injury and chronic indwelling urethral catheters.

INTRODUCTION: Bladder rupture in patients with indwelling urethral catheters is rare. Herein, we describe two spinal cord injured (SCI) patients with neurogenic bladder dysfunction managed with chronic indwelling catheters who presented with extraperitoneal bladder rupture related to bladder instillation. One case was during continuous bladder irrigation for hematuria, the other during routine cystography. CASE PRESENTATION: One patient is a tetraplegic male with a C5 ASIA impairment scale (AIS) SCI and a chronic catheter who presented with gross hematuria and autonomic dysreflexia (AD). Continuous irrigation was complicated by ongoing AD and poor catheter drainage. A CT scan revealed an extraperitoneal bladder rupture which was managed with surgical repair and suprapubic catheter. The second patient is a tetraplegic female who underwent gravity cystography to evaluate for vesicoureteric reflux. She experienced AD, followed by a witnessed extraperitoneal rupture. The rupture resolved with continued catheter drainage. No long term complications were noted. DISCUSSION: We present two cases of extraperitoneal rupture in chronically catheterized SCI patients following bladder instillation. Both patients were undergoing instillation of fluid through balloon catheters which likely occluded the outlet. We believe that rupture in both cases was iatrogenic, from elevated intravesical pressures during gravity instillation of fluid. Both patients experienced AD during these events. A procedure involving bladder instillation in chronically catheterized SCI patients should be performed by providers familiar with management of AD. Risk factors for iatrogenic bladder rupture during instillation procedures likely include chronic catheterization, small bladder capacity, instillation under significant pressure, and occlusion of the bladder outlet by a balloon catheter.

Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience.

PURPOSE: To identify incidence and predictors of stress urinary incontinence (SUI) following Holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: We performed a retrospective review of 589 HoLEP patients from 2012-2018. Patients were assessed at pre-operative and post-operative visits. Univariate and multivariate regression analyses were performed to identify predictors of SUI. RESULTS: 52/589 patients (8.8%) developed transient SUI, while 9/589 (1.5%) developed long-term SUI. tSUI resolved for 46 patients (88.5%) within the first six weeks and in 6 patients (11.5%) between 6 weeks to 3 months. Long-term SUI patients required intervention, achieving continence at 16.4 months on average, 44 men (70.9%) with incontinence were catheter dependent preoperatively. Mean prostatic volume was 148.7mL in tSUI patients, 111.6mL in long-term SUI, and 87.9mL in others (p < 0.0001). On univariate analysis, laser energy used (p < 0.0001), laser "on" time (p=0.0204), resected prostate weight (p < 0.0001), overall International Prostate Symptom Score (IPSS) (p=0.0005), and IPSS QOL (p=0.02) were associated with SUI. On multivariate analysis, resected prostate weight was predictive of any SUI and tSUI, with no risk factors identified for long-term SUI. CONCLUSION: Post-HoLEP SUI occurs in ~10% of patients, with 1.5% continuing beyond six months. Most patients with tSUI recover within the first six weeks. Prostate size >100g and catheter dependency are associated with increased risk tSUI. Larger prostate volume is an independent predictor of any SUI, and tSUI.