Vesico-ureteric reflux (VUR) management and screening patterns: are paediatric urologists following the 2010 American Urological Association (AUA) guidelines?

OBJECTIVE: To evaluate the current practice patterns of vesico-ureteric reflux (VUR) management and screening among paediatric urologists and their relationship with the current American Urological Association (AUA) guidelines in managing and treating VUR. SUBJECTS AND METHODS: A 17-question survey was sent out to 476 paediatric urologists who are members of the Society for Pediatric Urology (SPU). In all, 133 respondents answered the survey and results were included for all questions. RESULTS: Paediatric urologists who were surveyed were consistent with the 2010 AUA guidelines in the initial evaluation of children with VUR, continuous antibiotic prophylaxis for the child aged < or >1 year, and follow-up evaluation in children with VUR. Most paediatric urologists do not obtain a serum creatinine on initial screening of children with VUR. The new guidelines address screening of siblings of patients with VUR and most paediatric urologists were consistent with these recommendations. Almost one third of responders screened all neonates diagnosed with prenatal hydronephrosis regardless of clinical history or findings on imaging despite the recommendations of the new guidelines. CONCLUSION: We conclude that based on our present sample, most paediatric urologists follow the 2010 AUA guidelines on VUR management.

Robot-assisted urologic surgery: safety and feasibility in the pediatric population.

PURPOSE: To assess the safety and feasibility of performing robot-assisted pediatric urologic surgery with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) based on our experience with a variety of procedures. PATIENTS AND METHODS: A retrospective review was performed of 53 robot-assisted pediatric procedures performed in our practice between September 2003 and March 2006. The procedures included 11 renal extirpative surgeries, 10 orchiopexies, 26 dismembered pyeloplasties, 2 uretero-ureterostomies, and 3 bladder surgeries. The mean patient age was 7.7 years, and the mean patient weight was 32 kg. All procedures were performed transperitoneally. RESULTS: All procedures were successfully completed with no conversions to open surgery. There was one procedure in which the robotic system malfunctioned, resulting in an unrecoverable loss of three-dimensional visualization and temporary loss of color. The only postoperative complication involved delayed return of bowel function that led to a diagnostic laparotomy with negative findings. A decrease in mean postoperative stay was noted in patients who underwent robot-assisted procedures compared with previous patients who had undergone open surgery. CONCLUSION: Robot-assisted surgery appears to be safe and feasible for a variety of pediatric urologic procedures. Prospective randomized studies are required to further evaluate the outcomes compared with open surgical procedures. Our initial experience has been encouraging and will serve as a foundation for future and more complex minimally invasive pediatric urologic operations.

The Current State of Urological Education for Medical Students.

INTRODUCTION: Providing medical students with a basic urological education is important as the geriatric population expands and the need for urological care increases. In the last decades there have been considerable changes to medical school curricula and graduation requirements that may impact medical student exposure to urology. We reviewed the literature pertaining to urological education for medical students in the United States. METHODS: We searched the PubMed® and Medline® databases to identify articles pertaining to medical student education in urology. We summarized these articles according to 4 themes, including 1) medical student electives in urology, 2) medical student career interest in urology, 3) new interventions in urology education and 4) the urology match. RESULTS: We identified 25 articles, which showed that 1) medical student exposure to urology has markedly declined, 2) medical students remain highly interested in pursuing a career in urology, 3) the AUA (American Urological Association) medical student curriculum has provided a key resource for medical school urological education and 4) applying for urology residency may be expensive and challenging. CONCLUSIONS: Medical school urological education has changed in the last decades. Although it appears that fewer medical students are required to rotate through urology, new materials are available to educate medical students in urology and many students are highly interested in pursing a career in the field.

Up and Away: Five Decades of Urologic Investigation in Microgravity.

A renewed global interest in manned space exploration has emerged, propelled by the challenge of reaching a new frontier: travel to the Red Planet, Mars. As the physiological changes induced by microgravity bear direct relevance to the safety and viability of these goals, we provide a historical narrative of the urologic investigations in space. We review the significant contributions to the understanding of the urologic consequences associated with exposure to microgravity, considerations for prolonged missions, and forward-looking efforts to manage emergent conditions remotely. Historical insights gleaned are poised to inform interplanetary travel, where urologic pathology will remain an important practical consideration.

Challenges Facing Program Directors in the Urology Match.

INTRODUCTION: We investigate urology residency program directors' perspectives on the current residency matching system. METHODS: A survey was emailed to Society of Urology Chairpersons and Program Directors members. The survey queried respondents' perspectives on the current residency matching system, with special attention to the recent surge in application volume and the usefulness of the Medical Student Performance Evaluation. Participants were also asked about their perspective on a possible application limit for students applying to urology residencies. RESULTS: A total of 70 members of the Society of Urology Chairpersons and Program Directors responded to the survey. The majority of respondents received more than 200 applications for their program's residency positions (77.1%) and used a Step 1 cutoff score to screen applications (81.4%). Approximately half of the respondents (51.4%) were in favor of imposing a limit to the number of applications that applicants are permitted to submit. The Medical Student Performance Evaluation was considered important or very important by 20% and 94.3% favored including an applicant's class rank in the evaluation. An applicant's projected likelihood of attending a respondent's program was considered by 76%, and 60% had previously not offered superior candidates interviews because they estimated the applicants were not truly interested in the program. CONCLUSIONS: Urology program directors exclude a large number of applications based on board scores and applicants' perceived levels of interest in the programs. A significant number of program directors favored an application limit as well as including class rank in the Medical Student Performance Evaluation.

The Current State of Urological Residency Education.

INTRODUCTION: We reviewed literature pertaining to the current state of urological education for residents in the United States. METHODS: A literature review was performed to identify relevant manuscripts using a key word search of the PubMed® and MEDLINE® databases. Central themes of the literature were identified and summarized for the purpose of this review. RESULTS: A literature search identified 23 articles related to urological residency education. Key themes identified in the available literature included surgical simulation, decreasing open experience, and improving the efficiency and quality of resident education and evaluation. With increasing limitations in available resident training hours as well as increasing utilization of minimally invasive approaches in the field of urology it is important to critically assess how urological residents are trained. CONCLUSIONS: As the scope and complexity of medical knowledge and surgical approaches evolve in the field of urology it is imperative to critically evaluate how urological residents are trained to ensure that graduating residents are prepared to provide outstanding patient care as independent surgeons.

Fluid Management in Pediatric Urology: A Review of the Literature and Call for a Change in Practice.

INTRODUCTION: We investigate the intravenous fluid ordering practices of pediatric urologists. We also provide evidence for the use of isotonic fluids and, thus, establish a new standard for the field. METHODS: An online questionnaire was distributed via the listserve of the American Academy of Pediatrics Section on Urology. For 3 patient scenarios the respondents were asked to select which intravenous fluid they would prescribe and which infusion rate they would choose. Fluid choices were listed as lactated Ringer solution, normal saline, 0.45% normal saline, 5% dextrose in lactated Ringer solution, 5% dextrose in 0.45% normal saline, none and other (with write-in option). Infusion rate choices were listed as maintenance (defined according to the Holliday-Segar 4-2-1 nomogram), ½x maintenance, 1.5x maintenance, 2x maintenance and other (with write-in option). A final question probed physician reason(s) for selections. RESULTS: The survey had a 35% response rate. The majority of respondents use 5% dextrose in 0.45% normal saline, and the most common infusion rate is 1.5x maintenance. Additionally, choices for fluid use and infusion rate were based on a combination of physician training and personal experience. Only 13% of respondents stated that they routinely avoid isotonic fluids. A PubMed® literature search demonstrated that the general pediatric and surgical specialty literature discourages hypotonic fluids and favors the judicious use of isotonic hydration and dextrose. CONCLUSIONS: A change in pediatric urology needs to occur such that isotonic fluids at maintenance rate become the standard, with the addition of dextrose and/or increasing of rate only for carefully selected patients.

Program directors' criteria for selection into urology residency.

OBJECTIVE: To investigate urology residency program directors' criteria for resident selection. METHODS: In 2014, the urology residency program directors were surveyed using an email questionnaire. The generated questionnaire included the following 3 components: (1) assessing the factors used in selecting applicants for interviewing and matching, (2) rating the factors resulting in a negative decision for applicants for interviewing and matching, and (3) investigating the factors that gave applicants special attention or consideration from program directors. Analysis of variance testing and post hoc Student t tests were used to assess for differences in the mean importance score of the factors. RESULTS: Urology reference letters and United States Medical Licensing Examination (USMLE) scores were ranked as the most important factors for applicant selection. A USMLE Step 1 score ≤220 and a USMLE Step 2 score ≤220 were the most deleterious factors to applicants, with a previous match failure being no less deleterious to an applicant than a USMLE Step 1 or 2 score ≤220. Program directors gave special attention or consideration to gender (25%), minority status (36.8%), being from the same medical school as the program director (61.8%), completing an away rotation at the program director's institution (86.8%), being a child of an academic urologist (47.4%), and being a child of an academic nonurologic physician (15.8%). CONCLUSION: Although program directors consider a variety of factors during the residency selection process, USMLE performance, urology references, and completing an away rotation at the program directors' institution appear to be the most important factors to program directors during the residency selection process.

Relationship Between the Number of Residency Applications and the Yearly Match Rate: Time to Start Thinking About an Application Limit?

BACKGROUND: There has been an increase in the number of applications medical students have submitted for the National Residency Matching Program (NRMP). These additional applications are associated with significant costs and may contribute to match inefficiency. OBJECTIVE: We explored if match rates improved in years when an increased number of applications were submitted. METHODS: We analyzed yearly published data from the NRMP and the Electronic Residency Application Service for 13 specialties. A generalized linear model was used to assess the relationship between the annual match rate and the mean number of applications submitted per applicant, while controlling for the number of positions available and the number of applicants in the given year. RESULTS: Over the last 13 years there has been an increase in the mean number of applications submitted per applicant (P < .001). For the 13 assessed medical specialties, there was no statistically significant relationship between the mean number of applications per applicant per year submitted to the NRMP, and the annual match rate (odds ratios near 1.00 and nonsignificant, P values > .05). CONCLUSIONS: There was no improvement in the match rate in years when medical students submitted an increased number of applications. Therefore, it would appear that the applicants do not benefit from the larger number of applications submitted. Further study is required to assess the cost and benefit of these additional applications.

Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study.

OBJECTIVE: To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTIs) in persons with spinal cord injury (SCI). DESIGN: A prospective, double-blinded, placebo-controlled, crossover study. PARTICIPANTS: 21 individuals with neurogenic bladders secondary to SCI. MAIN OUTCOME MEASURES: Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts. METHODS: Individuals with neurogenic bladders due to SCI were recruited and randomly assigned to standardized 400-mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1-week "washout period," participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count > or = 10 per high power field) in centrifuged urine. Participants with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7-day washout period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead's random effect approach. RESULTS: There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups. CONCLUSION: Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders. Further long-term studies evaluating specific types of bladder management and UTIs will help to determine whether there is any role for the use of cranberries in individuals with neurogenic bladders.