Impact of County Rurality and Urologist Density on the Practice of Inguinal Lymph Node Dissection and Mortality in Patients Diagnosed with Squamous Cell Carcinoma of the Penis.

BACKGROUND: Inguinal lymphadenectomy (LND) is influential in reducing the mortality of squamous cell carcinoma of the penis (SCCP). We investigated the impact of urologic workforce density (UD) and rural residence (RR) on the practice of LND and mortality of SCCP (SCCP-RM). MATERIALS AND METHODS: UD was determined from the 2014 to 2015 Area Health Resource File data, while RR was determined using the 2003 rural-urban continuum codes. All cases of SCCP within the surveillance, epidemiology, and end results 18 registry with known county codes were used for analysis (n = 2863). RESULTS: Overall, 48.69% of cases lived in a county with less than the mean UD, 8.38% lived in counties with no urologists, 14.60% lived in a rural county, and 19.2% (n = 550) had LND performed. UD and RR had no impact on the prevalence of LND, number of lymph nodes examined, or the mean number of lymph nodes positive for SCCP (all p > 0.05). Adjusted analysis indicated that older patients and patients with regional stage of cancer were at a greater risk for post-LND SCCP-RM (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.28-2.21, and HR 4.32, 95% CI 3.09-6.06, respectively). There was no difference in the HR of SCCP-RM dependent on race, marital status, education, RR, UD, or LND. CONCLUSION: While demand on the urologist workforce has increased in rural demographics, no impact of limited access to urologists on the practice of LND in SCCP could be identified in this study. In addition, there was no significant difference in the risk of SCCP-specific mortality related to lower UD or RR.

Practice patterns of female urologists in Australia and New Zealand.

OBJECTIVE: To analyse the practice patterns of female urologists in Australia and New Zealand. PARTICIPANTS AND METHODS: An electronic survey was sent to female urologists and urology trainees of the Urological Society of Australia and New Zealand in December 2016, with questions on demographics, practice patterns and views on mentorship. RESULTS: Of 82 recipients of the questionnaire, 60 (73.2%) responded. Of these, 61.7% were aged <40 years, 81.7% were married or in a long-term relationship and 56.7% had children. A total of 67.8% had completed urology training. Of these, most had commenced clinical practice within the preceding 12 years, most had taken no time off in training and most had taken <1 year away from clinical practice. A total of 74.4% practised in a metropolitan area and 42.5% described their practice as being general urology. High or moderate satisfaction levels were reported by 88.1% of respondents and 92.9% intended to retire before the age of 70 years. A total of 17.2% had not had a mentor and 80.7% thought a mentorship scheme would be useful. CONCLUSION: These results provide information on the practice patterns of the increasing number of women urologists in Australia and New Zealand and have the potential to shape workforce and training planning in this region and worldwide.

Training of Tunisian future urologists: how to improve it ?

BACKGROUND: The lack of continuous evaluation of training tools in medicine, especially in developing countries, represents a brake to the development of the latter. AIM: To establish an inventory of the training facilities available to residents in urology in Tunisia, to assess their satisfaction and their expectations, and to propose solutions to improve residents training. METHODS: An anonymous questionnaire was sent by E-mail in 2015 to all residents in urology in Tunisia. The questionnaire addressed demographic characteristics, educational resources used and desired, the current medical and university curriculum and evaluation of the training. RESULTS: Among 33 residents, 66.6% responded to the survey. Medical staff, courses organized by the national college of urology, reading french-language articles and daily activity in operating room were the most used pedagogic resources. Training was judged unsatisfactory by 59.1% of respondents because of a lack of theoretical training in 18.1% of cases, a lack of practical training in 13.6% of cases and both of them in 27.2% of cases. Training on animals and simulator, creation of an educational booklet, use of online course materials, and the institution of a mentoring process during residency were rated favorable by the majority of respondents. CONCLUSION: The majority of residents in urology in Tunisia believe their training is unsatisfactory. The E-learning, improved access to surgical training in animals and simulator, better information on existing resources and strengthening of companionship through tutoring should enhance satisfaction.

Revitalizing Urologists' Role in Transplantation as a Novel Strategy to Address Surgeon Shortage: Results from a Cross-Sectional Survey.

OBJECTIVES: Urologists represent functional alternatives for transplant surgeons, but their involvement is minimal. Evaluating urologists' interests in transplant and identifying associated factors may help to determine whether recruitment of more urological providers is a viable strategy to address transplant surgeon shortages in the United States. MATERIALS AND METHODS: We emailed a 10-question survey to individuals pursuing urology in the United States and collected demographic data, education and training backgrounds, and preferences for proposed integrated residency programs and abbreviated transplant fellowships. We stratified respondents based on transplant interest (yes/no); we made comparisons by using t-tests for continuous variables and Fisher exact tests for categorical variables. We used multivariable logistic regression to identify factors associated with interest in transplant surgery. RESULTS: Of 104 respondents, 98 were included in the final analysis, with 47% indicating a current or prior interest in transplantation. Male respondents were 3.7 times more likely than female respondents to be interested (odds ratio = 4.675; 95% CI, 1.411-15.495; P = .012). Participants aged <30 years were 93% less likely than older participants to be interested in transplantation (odds ratio = 0.071; 95% CI, 0.006-0.779; P = .03). International medical graduates reported higher enthusiasm for transplantation compared with US-trained counterparts (89% vs 42%), with a trend toward significance (P = .06). Nearly all (93%, 43/46) who expressed interest endorsed having an integrated training pathway. Only 70% (32/46) supported an abbreviated fellowship (<24 mo). Lifestyle concerns and insufficient exposure during residency were the most frequently cited reasons for lack of interest. CONCLUSIONS: Compared with male and older urology trainees, female and younger urology trainees were less inclined to pursue transplant surgery. Nonetheless, urologists represent an untapped pool of transplant surgeons. Proposing an integrated training program for urologists and increasing exposure to transplantation during urology residency represent potential strategies to decrease transplant surgeon shortages.

The Future State of Race/Ethnicity in Urology: Urology Workforce Projection From 2021-2061.

OBJECTIVE: To project the proportion of the urology workforce that is from under-represented in medicine (URiM) groups between 2021-2061. METHODS: Demographic data were obtained from AUA Census and ACGME Data Resource Books. The number of graduating urology residents and proportion of URiM graduating residents were characterized with linear models. Stock and Flow models were used to project future population numbers and proportions of URiM practicing urologists, contingent on assumptions regarding trainee demographics, retirement trends, and growth in the field. RESULTS: Currently, there is an increase in the percentage of URiM graduates by 0.145% per year. If historical trends continue, URiM urologists will likely comprise 16.2% of urology residency graduates and 13.3% of the practicing urological workforce in 2061. These percentages would constitute an underrepresentation of URiM urologists relative to the projected 44.2% of the U.S. population who would identify as American Indian/Alaskan Native, Black/African American, Latinx/Hispanic and Native Hawaiian/Pacific Islander by 2060.1 An increase in the percentage of URiM graduates by 0.845% per year would result in 44.2% URiM urology residency graduates and 26.1% URiM practicing urologists by 2061. An interactive app was designed to allow for a range of assumptions to be explored and for future data to be incorporated. CONCLUSION: URiM physician representation within urology over the next 40years will remain disproportionately low compared to that of the projected share of people of color in the general U.S. POPULATION: In order to achieve the AUA's Diversity, Equity and Inclusion goals, a concerted effort to implement interventions to recruit, train, and retain a generation of racially diverse urologists appears necessary.

An Analysis of American Urological Association Census Trends: Earlier Planned Retirement and Practice Pattern Changes May Exacerbate the Urology Workforce Shortage.

OBJECTIVE: To explore how changes in planned retirement age, practice setting, and physician productivity may impact the workforce shortage in urology. METHODS: We compared data between the 2015 and 2022 American Urological Association census, a specialty-wide annual survey which collects data on demographics, practice patterns, and procedures from a representative sample of U.S. urologists. Workforce productivity was measured by the self-reported number of hours worked per week and patients seen per week. A novel formula was developed to demonstrate how planned retirement age and productivity impact the workforce's production capacity. RESULTS: The total number of practicing urologists increased during the period from 2015 to 2022 (11,990 to 13,976), while the mean age of practicing urologists decreased slightly (55.0 to 54.5years; P < .002). During this period, the mean planned age of retirement for all urologists decreased from 68.9years to 67.7 (P < .001). Urologists in solo practice had a significantly higher planned age of retirement at 71.9years (P < .001) as compared to all other practice models. The number of patients seen per week for all urologists decreased from 78.7 to 72.9 (P < .001). The amount of hours worked per week remained relatively constant between the study periods. The maximum possible number of patients seen by the workforce prior to retirement increased by only 2.4% during the study interval. CONCLUSION: Though the U.S. urology workforce is growing and the mean age is decreasing, decreases in planned retirement age and productivity may offset these gains and intensify the physician shortage for U.S. urologists.

Projected US Urology Workforce per Capita, 2020-2060.

Importance: Projections to 2035 have demonstrated concern regarding a worsening urology workforce shortage. Objective: To project the size and demographic characteristics of the urology workforce per capita into 2060 and to anticipate the timing and degree of the impending urology workforce shortage. Design, Setting, and Participants: This population-based cross-sectional study used the 2019 American Urological Association Annual Census data and the Accreditation Council for Graduate Medical Education's Data Resource Book from 2007 to 2018. The cohort included practicing urologists in 2019. US Census data were used to approximate the projected US population. Data analysis was performed from June 2020 to March 2021. Exposures: Continued growth stock and flow model of 13.8% and stagnant growth model of 0% increase of the incoming urology workforce with cohort projection per projected US population. Main Outcomes and Measures: The primary outcome was urology workforce projection per the population aged 65 years and older. Urology workforce projections per capita and demographic characteristics of the urology workforce up to 2060 were calculated under guided assumptions with 2 stock and flow models. Results: In 2019, there were 13 044 urologists (11 758 men [90.1.%]; 1286 women [9.9%]; median age range, 55-59 years), with 3.99 urologists per 100 000 persons and 311 new urologists entering the workforce. In a continued growth model, 2030 will have the lowest number of urologists per capita of 3.3 urologists per 100 000 persons, and recovery to baseline will occur by 2050. There are 23.8 urologists per 100 000 persons aged 65 years and older in 2020, which decreases to 15.8 urologists per 100 000 persons aged 65 years and older in 2035 and never recovers to its baseline level by 2060. In a stagnant growth model, there will be a continued decrease of urologists per capita to 3.1 urologists per 100 000 persons by 2060. There is a continued decrease in per capita urologists at each time point, with 13.1 urologists per 100 000 persons aged 65 years and older by 2060. Conclusions and Relevance: With the impending urology workforce shortage, there will be an exaggerated shortage of total urologists per persons aged 65 years and older in both models. This projection highlights the need for structural changes and advocacy to maximize the available urology workforce.

Urology Workforce Changes and Implications for Prostate Cancer Care Among Medicare Enrollees.

OBJECTIVE: To characterize national trends in urologist workforce, practice organization, and management of incident prostate cancer. METHODS: Using Medicare claims data from 2010 to 2016, we identified all urologists billing Medicare and the practice with which they were affiliated. We characterized groups as solo, small single specialty, large single specialty, multispecialty, specialist, or hospital-owned practices. Using a 20% sample of national Medicare claims, we identified all patients with incident prostate cancer and identified their primary treatment. RESULTS: The number of urologists increased from 9,305 in 2010 to 9,570 in 2016 (P = .03), while the number of practices decreased from 3,588 to 2,861 (P < .001). The proportion of urologists in multispecialty groups increased from 17.1% in 2010 to 28.2% in 2016, while those within solo practices declined from 26.2% to only 15.8% over the same time period. A higher proportion of patients at hospital-owned practices were treated with observation (P < .001) and surgery (P < .001), while a higher proportion of patients at large single specialty practices were treated with radiation therapy (P < .001). CONCLUSION: We characterized shifts in urologist membership from smaller, independent groups to larger, multispecialty or hospital-owned practices. This trend coincides with higher utilization of observation and surgical treatment for prostate cancer.

Workforce Issues in Urology.

The future supply of urologists is not on pace to account for future demands of urologic care. This impending urologic shortage sits on a backdrop of multiple other workforce issues. In this review, we take an in-depth look at several pressing issues facing the urologic workforce, including the impending urology shortage, gender and diversity concerns, growing levels of burnout, and the effects of the coronavirus pandemic. In doing so, we highlight specific areas of clinical practice that may need to be addressed from a health care policy standpoint.

The Role of Advanced Practice Providers in Urology.

The nation's undersupply of urology services disproportionately affects Medicare beneficiaries compared to the general population. Advanced Practice Providers (APPs), most commonly nurse practitioners and physician assistants may be a vehicle to meet this need. The increased use of APPs in urology is hampered by physician discomfort with delegating responsibility to APPs. This discomfort may be compounded by complexities with billing issues and interstate variation in scope of practice regulations. To expand access to urological services while simultaneously ensuring service quality, it is imperative that urologists engage with APPs individually and as a specialty.

Promotional Payments Made to Urologists by the Pharmaceutical Industry and Prescribing Patterns for Targeted Therapies.

OBJECTIVE: To measure the association between market-level promotional payments to urologists by the manufacturers of abiraterone and enzalutamide and national prescribing patterns. METHODS: A 20% national sample of the 2015 Part D event file was used to identify patients filling their first prescription for abiraterone and enzalutamide and their prescribing physicians. The 2015 Open Payments data were used to characterize promotional payments made to physicians at the market level. Generalized linear models were then used to measure the relationship between market-level payments to urologists and the physician specialty prescribing abiraterone or enzalutamide for the first time RESULTS: In 2015, 2318 men filled a prescription for abiraterone or enzalutamide by a urologist or medical oncologist. Increasing market-level promotional payments to urologists for abiraterone or enzalutamide was strongly associated with a urologist prescribing either drug-24.3% versus 5.8% of those residing in the markets with highest and lowest level of promotional payments to urologists, respectively (P <.01). Neither the number of urologists residing in a market nor other promotional payment measures (ie, to medical oncologists for these drugs, or to all physicians for all other drugs) were associated with a urologist prescribing either drug. CONCLUSION: Promotional payments to urologists at the market level are strongly associated with the specialty of the physician prescribing abiraterone or enzalutamide for the first time. Future work should elucidate the effects of the shift in prescribing patterns on quality of care and financial hardship for men with advanced prostate cancer.

[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

The implications of fellowship expansion on future pediatric urologist surgical volumes.

INTRODUCTION: Over the past 25 years, Pediatric Urology fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) have more than doubled. This increase may lead to a significant decrease in the number of operative cases per surgeon and therefore impact the current practice of pediatric urology. OBJECTIVE: The objective in conducting this study is to try and predict the effect of the current number of pediatric urology fellowship training positions on future case volume per surgeon using a mathematical model and to discuss future management of the pediatric urology workforce. DESIGN: The current study employed a mathematical model to predict the effect of the number of fellowship graduates on future "case volume per surgeon". We incorporated population growth rates, to calculate incidence rates of key procedures/conditions and the anticipated retirement rate of the current pool of pediatric urologists to help calculate this. RESULTS: There is a possibility to increase the number of practicing board-certified pediatric urologists in the next 30 years from approximately 325 to 900 (figure). There will be a twofold reduction in case volume per surgeon compared to the present in model 1. In model 2 the decrease in case volumes is less significant. The annual number of fellows needed to obtain a future-to-current ratio equal to 1 is 16 for model 1, and 26 for model 2. DISCUSSION: Our study demonstrates, by using two different models that the current number of pediatric urology fellowship training positions in the United States will ultimately lead to a significant decrease in the case volume per surgeons. Our model has limitations as it relies on multiple assumptions. We are assuming that all fellowship positions would be filled every year and that all fellows would graduate, establish their practices in the United States, and devote 100% of their assumed 30-year professional career to pediatric urology. We also made assumptions of disease occurrence and need for surgical correction. The final assumption we made was that the birth rate would stay static over the next 30 years even though it has been declining for many decades. CONCLUSION: This exercise, even with its inherent limitations, is still sufficient to demonstrate that fellowship expansion warrants thoughtful discussion.

Increasing Urologic Care Ratios: Implications of Male Patient Care in Florida.

Ongoing trends have revealed an inverse relationship between population growth and the number of practicing urologists in the U.S. per capita, which threatens urologic care accessibility. Furthermore, different regions in the United States may be more negatively impacted due to higher population growth rates. The state of Florida witnessed over a 10% higher growth rate compared with national figures between 2000 and 2015. Coupled with data suggesting that since the 1980s, the number of U.S. urologists per capita has been decreasing, the foreseeable future presents many challenges regarding health equity and accessibility. This secondary analysis aimed to investigate the implications of forecasted urologic care decline within a growing population and how it can contribute to adverse male health outcomes. National- and state-level data were collected to calculate a series of urologic care ratios as defined by the number of urologists compared with population sizes. Analyses revealed that national-level urologic care ratios and prostate cancer incidence rates have a significant positive relationship, lending to the conclusion that with fewer urologists, the number of cases identified will decrease. State-level forecasted models indicated that the urologic care ratio will decrease approximately 30% in Florida from 6.23 per 100,000 in 2010 to 4.39 per 100,000 by the year 2030. As growth in demand for urologic care will increase in the next decade, a dire public health scenario is potentially unfolding. Future implications of undiagnosed prostate cancer due to the lack of access will drive an increase in mortality rates as well as health equity concerns for men.

Over-the-counter medication availability could augment self-management of male lower urinary tract symptoms.

In this review, we focus on current trends in the management of male lower urinary tract symptoms (LUTS), defined here as LUTS, namely, storage, voiding, and post-micturition symptoms presumed secondary to benign prostatic hyperplasia (BPH), and discuss possible novel approaches toward better care. According to results of a PubMed database search covering the last 10 years and using keywords pertaining to male LUTS, this condition continues to be globally undiagnosed or diagnosed late, partly because of men's hesitation to seek help for perceived embarrassing problems or problems considered a normal part of aging. In addition, the prevalence of male LUTS is continually increasing because of a constantly aging population. Male LUTS can be bothersome and affect the quality of life (QoL) and sexual function. Additional effective alternatives for managing this condition need to be identified and incorporated into the current care model. Considering that most male LUTS such as frequency, hesitancy, urgency, and intermittency are easy to self-identify, a self-management approach toward male LUTS is proposed. Limited evidence supports the efficacy of phytotherapies and herbals as self-management options for male LUTS. However, introducing over-the-counter (OTC) medication with proven efficacy, accompanied by lifestyle and behavioral modifications, may be a promising approach that will encourage more men to treat their symptoms in a timely manner. Formal guidelines, along with appropriate education programs for patients and support from the healthcare community, will be needed to ensure that the promise of this approach is fully materialized.

The future prospects of supply and demand for urologists in Korea.

Purpose: The purpose of this study was to forecast the future supply and demand for urologists and to discuss the possible policy implications. Materials and Methods: A demographic utilization-based model was used to calculate the total urologist requirements for Korea. Utilization rates for ambulatory and inpatient genitourinary specialty services were estimated according to age, sex, and insurance status. These rates were used to estimate genitourinary specialty-specific total service utilization expressed in patient care minutes for future populations and converted to genitourinary physician requirements by applying per-genitourinary-physician productivity estimates. An in-and-out movement model for urologist supply was used. Results: Depending on assumptions about data at each step in the method, the supply of urologic surgeons is expected to exceed the demand by 2025 under the current enrollment rate of specialists (43.5% in 2012) when comparing the results of the projections under demand scenarios 3 and 4. However, if the current enrollment rate persists, the imbalance in supply and demand will be not severe by 2030. The degree of imbalance can be alleviated by 2030 by maintaining the current occupancy rate of urologic residents of 43.5%. Conclusions: This study shows that the number of residents needs to be reduced according to the supply and demand for urologic surgeons. Moreover, a policy should be established to maintain the current occupancy rate of residents. The factors affecting the supply and demand of urologic surgeons are complicated. Thus, comprehensive policies encompassing these factors should be established with appropriate solutions.

Prevalence and management status of urologic diseases in geriatric hospitals in South Korea: A field research.

PURPOSE: We aimed to investigate the current management status of urologic diseases in geriatric hospitals in South Korea. MATERIALS AND METHODS: Questionnaire surveys and in-depth person-to-person interviews were conducted at 13 hospitals within the Seoul and Incheon areas. RESULTS: The study was carried out from July to December 2014; 75.6% of patients (1,858/2,458) and 77.5% (779/1,031) of medical personnel responded to our survey. All surveys and interviews were performed by urology specialists, fellows, residents, or nurses. The hospitals included in the study had an average of 215.2 beds (range, 110-367), 189.1 patients (range, 90-345), and 40.2 nurses (range, 10-83). The average number of physicians was 6.2 (range, 3-11), but none of these were certified urologists. Only 4 hospitals provided consultation services for urological disorders. In total, 64% of patients had urological disorders, although only 20.7% of patients were receiving medication. Most patients were being treated using urological interventions; diapers (49.7%), indwelling catheters (19.5%), clean intermittent catheters (12.2%), and external collection urinary drainage (7.9%). However, most interventions were inadequately implemented, and only 17% of the patients had been examined by a certified urologist. Urological complications were found in 20.2% of patients, and secondary complications occurred in 18.8%. Excluding redundant cases, the total prevalence of urological complications was 39.0%. CONCLUSIONS: Urologic diseases are poorly managed, and no certified urologists work in geriatric hospitals. Therefore, more designated urologists are needed in geriatric hospitals.