Burnout: A Call to Action From the AUA Workforce Workgroup.

PURPOSE: We hypothesize burnout has failed to improve and certain demographics may be disproportionately affected. MATERIALS AND METHODS: The AUA Workforce Workgroup examined work from the annual AUA Census over the past several years. Particular to this study, relevant burnout-related data were examined from the past 5 years. RESULTS: In 2021, 36.7% of urologists reported burnout compared to 36.2% in 2016. Burnout in men decreased from 36.3% to 35.2%, but increased in women from 35.3% to 49.2%. When examined by age, the largest increases in burnout were seen in those <45 years old, increasing from 37.9% to 44.8%, followed by 45-54 years old, increasing from 43.4% to 44.6%. When asked about the effect of COVID-19 on burnout, 54% of urologists didn't feel COVID-19 impacted burnout. Beyond burnout, only 25.0% of men and 4.6% of women reported no conflict between work and personal responsibilities, while 25.7% of men and 44.7% of women resolved these conflicts in favor of work or were unable to resolve them. Of respondents, 22.5% of men and 37.1% of women were "dissatisfied" with work-life balance. Similarly, 33.6% of men reported their work schedule does not leave enough time for personal/family life, compared to 57.5% of women. CONCLUSIONS: Overall, urologists have higher burnout now when compared to 2016. The gender discrepancy has vastly widened with women experiencing burnout at an increased rate of 14% compared to 2016, while burnout in men decreased by 1%. Burnout has increased the most in those <45 years old. Further action is needed to substantiate the causes of burnout.

Advancements in Surgical Performance Evaluation and Feedback.

PURPOSE OF REVIEW: How today's urology trainees acquire surgical skills has changed dramatically due to multiple forces placing strain on the graduate medical education mission. The development of workplace-based assessments that deliver feedback while capturing performance data has led to a paradigm shift toward individualized learning. RECENT FINDINGS: Delivering feedback that drives surgical skill development requires the educator to provide a meaningful assessment of the learner after an operative experience. Workplace-based assessment involves direct observation of routine clinical practice and has become a central component of competency-based medical education. Urology has the chance to fully embrace competency-based medical education, employing robust feedback mechanisms and workplace-based assessments. We must first define what it means to be a proficient urologist and design an assessment system that captures this collective sentiment. This can only be done through effective engagement and collaboration with stakeholders across our specialty.

SIMPLifying Urology Residency Operative Assessments: A Pilot Study in Urology Training.

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.

Trends in Procedures to Initiate Renal Replacement Therapy among People Living with Spina Bifida.

PURPOSE: Given the increasing prevalence of chronic kidney disease in people with spina bifida, we sought to determine if this is associated with an increase in end stage kidney disease. We examined population based data to measure the frequency of procedures to establish renal replacement therapy-a marker for end stage kidney disease-among patients with spina bifida. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database from Florida, Kentucky, Maryland and New York (2000 to 2014), which include encounter level data. With a diagnosis code based algorithm we identified all procedural encounters made by patients with spina bifida. We determined the percentage of these encounters that were for facilitating renal replacement therapy (ie arteriovenous anastomosis, renal transplantation). We assessed for changes over time in this percentage with the Cochran-Armitage trend test. Bivariate analysis was performed using chi-square test. RESULTS: Of all procedures performed on patients with spina bifida over this time the proportion of procedures performed to establish renal replacement therapy significantly decreased in both the inpatient and outpatient settings (p=0.042 and p <0.001, respectively). People with spina bifida undergoing procedures to establish renal replacement therapy were, on average, young adults (mean age 34.5 and 36.0 years) with a high prevalence hypertension (75.8% of inpatients, 68.6% of outpatients). CONCLUSIONS: The frequency of surgeries to initiate renal replacement therapy among people with spina bifida undergoing procedures is low and is not increasing. This highlights the importance of consistent care throughout adolescence and young adulthood, and hypertension screening.

Impact of the Image Gently® Campaign on Computerized Tomography Use for Evaluation of Pediatric Nephrolithiasis.

PURPOSE: The Image Gently® campaign was launched by several radiological societies in 2007 to promote safe imaging in children. A goal of the campaign was to reduce ionizing radiation exposure in children. Given the recurrent nature of kidney stones, affected children are at risk for unnecessary ionizing radiation exposure from computerized tomography. We sought to determine whether the Image Gently campaign led to a decrease in the use of computerized tomography for evaluating children with nephrolithiasis. We hypothesized that the campaign was the primary cause of a reduction in the use of computerized tomography. MATERIALS AND METHODS: We analyzed medical claims data from 2001 to 2015 identifying children with nephrolithiasis covered by the same commercial insurance provider. Using a difference in differences design, we estimated changes in computerized tomography use after the campaign started among patients less than 18 years old compared to a control group age 18 years or older with nephrolithiasis. RESULTS: We identified 12,734 children and 787,720 adults diagnosed with nephrolithiasis. Before 2007 quarterly rates of computerized tomography use during a stone episode (per 1,000 patients) were increasing at a parallel rate in children and adults (5.1 in children vs 7.2 in adults, p = 0.123). After the Image Gently campaign started the use of computerized tomography decreased in both groups but at a slightly higher rate in adults (difference in differences 2.96, 95% CI 0.00 to 5.91, p = 0.050). CONCLUSIONS: Although there has been a reduction in the use of computerized tomography among children with nephrolithiasis, given a similar trend seen in adults this change cannot be primarily attributed to the Image Gently campaign.

Interobserver and Intra-Observer Reliability of the Urinary Tract Dilation Classification System in Neonates: A Multicenter Study.

PURPOSE: The Urinary Tract Dilation classification system was designed to be more objective and reproducible than currently available grading systems. We evaluated the reliability and consistency of the system in newborns. MATERIALS AND METHODS: Of 1,046 infants 0 to 90 days old undergoing ultrasound for hydronephrosis 243 were randomly selected for study inclusion. Seven readers (4 radiologists and 3 urologists) at 4 institutions classified complete, de-identified ultrasound studies on a Web based platform. Interobserver and intra-observer agreement was evaluated using the Fleiss kappa statistic. RESULTS: Interobserver agreement for Urinary Tract Dilation risk score was moderate among the 7 readers (kappa = 0.421, 95% CI 0.404-0.438). Interobserver agreement using the Society for Fetal Urology scale was worse than with the Urinary Tract Dilation classification (kappa = 0.344, 95% CI 0.330-0.359). All 7 readers assigned the same Urinary Tract Dilation score in 19.3% of cases (47 of 243). In 38.7% of cases (94 of 243) at least 3 readers assigned a Urinary Tract Dilation score different from that assigned by the other readers. In 7% of cases (17 of 243) at least 3 readers assigned a score of P0/P1, while at least 3 readers scored the same cases as P2/P3. At least 3 different Urinary Tract Dilation risk scores were assigned to the same patient in 30.45% of patients (74 of 243). Among individual Urinary Tract Dilation elements calyceal dilatation and bladder status had the highest disagreement. Five readers regraded 80 cases and agreed with their previous Urinary Tract Dilation risk score in 63.8% to 75.0% of cases (kappa 0.458 to 0.729). CONCLUSIONS: Interobserver agreement using the Urinary Tract Dilation grading system is fair to moderate, with variable agreement on individual elements of the system. Agreement was higher for the Urinary Tract Dilation system compared to the Society for Fetal Urology scale.

Ambulatory Care Use among Patients with Spina Bifida: Change in Care from Childhood to Adulthood.

PURPOSE: We examined the ambulatory health care visit use of children with spina bifida, adults who transitioned to adult care and adults who continued to seek care in a pediatric setting. MATERIALS AND METHODS: We evaluated use during a 1-year period of patients with spina bifida who visited any outpatient medical clinic within an integrated health care system. Patients were categorized as pediatric (younger than 18 years) or adult (age 18 or older). Adults were divided into those who did not fully transition to adult care and patients who fully transitioned (adult). Frequency and type of health care use were compared. Subanalysis was performed for patients 18 to 25 years old to examine variables associated with successful complete transition to adult care. RESULTS: During 1 year 382 children, 88 patients who did not transition and 293 adult patients with spina bifida had 4,931 clinic visits. Children had greater ambulatory care use (7.25 visits per year) compared to fully transitioned adults (5.33 visits per year, p=0.046). Children more commonly visited surgical clinics (52.3% of visits) and adults more commonly visited medical clinics (48.9%) (p <0.005). Adult transitioned patients were more likely to be female (p=0.004). Of the patients 18 to 25 years old, those who did not transition to adult care had similar outpatient visit types but greater use of inpatient and emergency care than those who transitioned. CONCLUSIONS: Children with spina bifida used more ambulatory care than adults and were more likely to visit a surgical specialist. Adult patients with spina bifida who successfully transitioned to adult care were more likely to be female, and patients who failed to transition were more likely to receive more inpatient and emergency care.

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence.

PURPOSE: To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown. MATERIALS AND METHODS: Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period. RESULTS: Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use. CONCLUSIONS: The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.

The Nonpalpable Testis: A Narrative Review.

PURPOSE: While the nonpalpable testis represents a small portion of all cryptorchid testes, it remains a clinical challenge for pediatric urologists. Controversy exists surrounding the best evaluation and management of this entity. In this review we update what is known about the nonpalpable testis, including the etiology, preoperative evaluation and best surgical management as well as novel techniques and ongoing controversies. MATERIALS AND METHODS: We searched PubMed® and MEDLINE® from January 2000 to January 2017 using relevant key terms. Of 367 articles 115 were considered for inclusion based on a priori design. Using a narrative review format, an update on the evaluation and management of the nonpalpable testis including novel concepts and techniques was synthesized. RESULTS: The nonpalpable testis should be evaluated by physical examination only. Imaging is not indicated for routine cases. The optimal surgical approach and technique remain debatable but several novel techniques have been described. Due to the rarity of the nonpalpable testis, randomized controlled trials and other quality comparisons are difficult. Therefore, management remains controversial. CONCLUSIONS: Evaluation and management of the nonpalpable testis remain difficult, and some aspects are still debated. Future research should focus on multi-institutional collaborative trials to determine the optimal operative management.

Can Shear-Wave Elastography be Used to Discriminate Obstructive Hydronephrosis from Nonobstructive Hydronephrosis in Children?

PURPOSE: To determine if ultrasonographic (US) renal shear-wave speed (SWS) measurements obtained either before or after intravenous diuretic administration can be used to discriminate obstructive hydronephrosis from unobstructive hydronephrosis in children, with diuretic renal scintigraphy as the reference standard. MATERIALS AND METHODS: Institutional review board approval and parental informed consent were obtained for this HIPAA-compliant prospective cross-sectional blind comparison with a reference standard. Between November 2012 and September 2014, 37 children (mean age, 4.1 years; age range, 1 month to 17 years) underwent shear-wave elastography of the kidneys immediately before and immediately after diuretic renal scintigraphy (reference standard for presence of urinary tract obstruction). Median SWS measurements (in meters per second), as well as change in median SWS (median SWS after diuretic administration minus median SWS before diuretic administration) were correlated with the amount of time required for kidney radiotracer activity to fall by 50% after intravenous administration of the diuretic (T1/2). Median SWS measurements were compared with degree of obstruction and degree of hydronephrosis with analysis of variance. Receiver operating characteristic (ROC) curves were created. RESULTS: Radiotracer T1/2 values after diuretic administration did not correlate with median SWS measurements obtained before (r = -0.08, P = .53) or after (r = -0.0004, P >.99) diuretic administration, nor did they correlate with intraindividual change in median SWS (r = 0.07, P = .56). There was no significant difference in pre- or postdiuretic median SWS measurements between kidneys with scintigraphic evidence of no, equivocal, or definite urinary tract obstruction (P > .5) or for median SWS measurements between kidneys with increasing degree of hydronephrosis (P > .5). ROC curves showed poor diagnostic performance of median SWS in discerning no, equivocal, or definite urinary tract obstruction (area under the ROC curve ranged from 0.50 to 0.62). CONCLUSION: US SWS measurements did not enable discrimination of obstructive hydronephrosis from unobstructive hydronephrosis in children.

Orchiopexy without Transparenchymal Fixation Suturing: A 29-Year Experience.

PURPOSE: We sought to gain insight into the outcomes of nontunical orchiopexy through assessment of elective and emergent orchiopexies performed by a single surgeon from 1985 to 2014. We demonstrate that successful orchiopexy does not require a fixation suture that pierces the tunica albuginea. MATERIALS AND METHODS: We retrospectively analyzed 1,104 orchiopexies in patients 1 day to 25 years old performed by a single urologist during a 29-year period. A total of 155 procedures were performed in 101 patients to remedy torsion, and 949 procedures were performed in 778 patients for undescended testes. The orchiopexy method for all patients was the same, involving no transparenchymal fixation suture. Operative notes, followup appointments and long-term testicular condition were analyzed. Appropriate testicular size and position were considered successful outcomes. Testicular atrophy, suprascrotal location, torsion and long-term pain were considered undesired outcomes. RESULTS: Of the 1,104 orchiopexy cases evaluated 1,090 were deemed successful, with normal testicular position and size postoperatively. A total of 14 testes in 8 patients showed undesired outcomes (postoperative atrophy in 4 testes, long-term pain in 2 and failure to retain appropriate position postoperatively in 8). CONCLUSIONS: Orchiopexy avoiding transparenchymal suturing through the tunica albuginea is a successful approach for fixation of the testis in the scrotum. Considering the high rate of favorable outcomes with this technique, and assuming that tunical invasion negatively impacts spermatogenesis, we consider a tunical suture unnecessary.

Pediatric ureteropelvic junction obstruction: can magnetic resonance urography identify crossing vessels?

BACKGROUND: MR Urography (MRU) is an increasingly used imaging modality for the evaluation of pediatric genitourinary obstruction. OBJECTIVE: To determine whether pediatric MR urography (MRU) reliably detects crossing vessels in the setting of suspected ureteropelvic junction (UPJ) obstruction. The clinical significance of these vessels was also evaluated. MATERIALS AND METHODS: We identified pediatric patients diagnosed with UPJ obstruction by MRU between May 2009 and June 2014. MRU studies were evaluated by two pediatric radiologists for the presence or absence of crossing vessels. Ancillary imaging findings such as laterality, parenchymal thinning/scarring, trapped fluid in the proximal ureter, and presence of renal parenchymal edema were also evaluated. Imaging findings were compared to surgical findings. We used the Mann-Whitney U test to compare continuous data and the Fisher exact test to compare proportions. RESULTS: Twenty-four of 25 (96%) UPJ obstructions identified by MRU were surgically confirmed. MRU identified crossing vessels in 10 of these cases, with 9 cases confirmed intraoperatively (κ = 0.92 [95% CI: 0.75, 1.0]). Crossing vessels were determined to be the primary cause of UPJ obstruction in 7/9 children intraoperatively, while in two children the vessels were deemed incidental and noncontributory to the urinary tract obstruction. There was no significant difference in age or the proportions of ancillary findings when comparing children without and with obstructing vessels. CONCLUSION: MRU allows detection of crossing vessels in pediatric UPJ obstruction. Although these vessels are the primary cause of obstruction in some children, they are incidental and non-contributory in others. Our study failed to convincingly identify any significant predictors (e.g., age or presence of renal parenchymal edema) that indicate when a crossing vessel is the primary cause of obstruction.

Pediatric urethral catheter consultations: understanding driving factors.

PURPOSE: Pediatric urethral catheterization is often straightforward. However, it can be challenging and may require urological consultation. Possible critical factors are patient anatomy and comorbidities, and insertion technique. To better understand pediatric catheter consultations, we reviewed our experience. MATERIALS AND METHODS: All pediatric catheter consultations between July 2009 and June 2012 were identified. A retrospective review was then performed, focusing on demographics, reasons for consultation and difficulty of catheter placement. The 4 categories of difficulty noted were easy, challenging, extremely difficult and could not be placed. Patients were excluded from analysis if catheter placement was not needed, the consultation was for a catheterizable stoma or they were status post urological surgery. Statistical analyses were performed to evaluate associations between patient factors and difficulty of placement. RESULTS: A total of 93 consultations were identified, of which 57% were inpatient, 28% intraoperative and 15% other source. Of the inpatient consultations 75% were from an intensive care unit, the majority (80%) of which were for catheter placement, with the remainder for removal, nondraining catheter, trauma or other. After exclusions 65 patients remained, of whom 80% were male and 32% had a urological comorbidity. By difficulty level 69.2% of cases were easy, 15.4% were challenging, 9.2% were extremely difficult and 6.2% could not be placed. Location of consult, gender, urological comorbidity and history of prematurity were not significantly associated with difficult catheter placement. CONCLUSIONS: Pediatric catheter consultations are largely straightforward. Comorbidities do not significantly impact catheter placement. Correct catheter technique may be more important than patient comorbidities, giving us a basis to shape catheter insertion training within pediatric hospitals.