Predictors of Excellent Urology Residents at the Time of the Urology Match.

OBJECTIVE: To update our experience and report on features predictive of high-quality urology residents at the time of the urology match, because data predicting which medical students will mature into excellent urology residents are sparse. METHODS: We reviewed our experience with 84 urology residents who graduated from 2006 to 2023. Residents were independently scored 1-10 based on overall quality by the current and former Program Director. Discrepant scoring by >2 was resolved by an independent review. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression. RESULTS: Discrepant scoring >2 was noted in only 5 (6%) residents. Among the 84 residents, the median overall score was 7 (range 1-10) and 36 (43%) residents had an excellent score of 8-10. Univariably, higher USMLE step II score (P = .03), election to alpha omega alpha (P = .004), no negative interview comments (P = .002), honors in OB/Gyn (P = .048) and psychiatry clerkships (P = .04), and honors in all core clinical clerkships (P < .001) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (P = .003) and honors in all core clinical clerkships (P = .001) were independently associated with an excellent score (c-index 0.76). There were several notable features (sex, letters of recommendation, USMLE step I, externship at our institution, surgery clerkship grade, and rank list) that were not significantly associated with excellent residents. CONCLUSION: We demonstrate features associated with excellent urology residents, most notably no negative interview comments and an honors grade in all core clinical clerkships.

Effect of Preoperative Multiparametric Magnetic Resonance Imaging on Oncologic and Functional Outcomes Following Radical Prostatectomy.

Background: Advancements in imaging technology have been associated with changes to operative planning in treatment of localized prostate cancer. The impact of these changes on postoperative outcomes is understudied. Objective: To compare oncologic and functional outcomes between men who had computed tomography (CT) and those who had multiparametric magnetic resonance imaging (mpMRI) prior to undergoing radical prostatectomy. Design setting and participants: In this retrospective cohort study, we identified all men who underwent radical prostatectomy (n = 1259) for localized prostate cancer at our institution between 2009 and 2016. Of these, 917 underwent preoperative CT and 342 mpMRI. Outcome measurements and statistical analysis: Biochemical recurrence-free survival, positive margin status, postoperative complications, and 1-yr postprostatectomy functional scores (using the 26-item Expanded Prostate Cancer Index Composite [EPIC-26] questionnaire) were compared between those who underwent preoperative CT and those who underwent mpMRI using propensity score weighted Cox proportional hazard regression, logistic regression, and linear regression models. Results and limitations: Baseline and 1-yr follow-up EPIC-26 data were available for 449 (36%) and 685 (54%) patients, respectively. After propensity score weighting, no differences in EPIC-26 functional domains were observed between the imaging groups at 1-yr follow-up. Positive surgical margin rates (odds ratio 1.03, 95% confidence interval [CI] 0.77-1.38, p = 0.8) and biochemical recurrence-free survival (hazard ratio 1.21, 95% CI 0.84-1.74, p = 0.3) were not significantly different between groups. Early and late postoperative complications occurred in 219 and 113 cases, respectively, and were not different between imaging groups. Our study is limited by a potential selection bias from the lack of functional scores for some patients. Conclusions: In this single-center study of men with localized prostate cancer undergoing radical prostatectomy, preoperative mpMRI had minimal impact on functional outcomes and oncologic control compared with conventional imaging. These findings challenge the assumptions that preoperative mpMRI improves operative planning and perioperative outcomes. Patient summary: In this study, we assessed whether the type of prostate imaging performed prior to surgery for localized prostate cancer impacted outcomes. We found that urinary and sexual function, cancer control, and postoperative complications were similar regardless of whether magnetic resonance imaging or computed tomography was utilized prior to surgery.

A Contemporary Analysis of Ureteral Reconstruction 30-Day Morbidity Utilizing the National Surgical Quality Improvement Program Database: Comparison of Minimally Invasive vs Open Approaches.

Objectives: To characterize 30-day morbidity of upper ureteral reconstruction (UUR) and lower ureteral reconstruction (LUR) surgery by comparing open and minimally invasive surgery (MIS) approaches using a national surgical outcomes registry. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent UUR and LUR between 2007 and 2017. Primary endpoints included 30-day complications, transfusion, readmission, return to operating room (ROR), and prolonged postoperative length of stay (LOS). Multivariable logistic regression was performed to observe the association of MIS approach on 30-day outcomes. Results: Three thousand forty-two patients were identified with 2116 undergoing UUR and 926 undergoing LUR. Of 2116 patients undergoing UUR, 1733 (82%) were performed through an MIS approach. On multivariable analysis, open approach for UUR was associated with increased odds of any 30-day complication (odds ratio (OR) 1.6 [1.1-2.4]; p = 0.014), major complication (OR 1.8 [1.04-3.0]; p = 0.034), transfusion (OR 3.7 [1.2-11.5]; p = 0.025), ROR (OR 2.0 [1.0-3.9]; p = 0.047), and prolonged LOS (OR 5.4 [3.9-7.6]; p < 0.001). Of the 926 patients undergoing LUR, 458 (49%) were performed through an MIS approach. On multivariable analysis, open approach for LUR was associated with increased odds of any 30-day complication (OR 1.5 [1.1-2.1]; p = 0.028), minor complication (OR 1.7 [1.1-2.6]; p = 0.02), transfusion (OR 8.1 [2.7-23.7]; p < 0.001), and prolonged LOS (OR 4.2 [2.4-7.3]; p < 0.001). Conclusion: Utilization of a national surgical database revealed an open approach was associated with increased 30-day morbidity across multiple postoperative outcome measures. These findings suggest an MIS approach should be considered, when feasible, for upper and lower ureteral reconstruction.

Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis.

OBJECTIVE: To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices. PATIENTS AND METHODS: Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ2 tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation. RESULTS: The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001). CONCLUSION: In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

Telemedicine in Urology: The Socioeconomic Impact.

The emergence of the COVID-19 pandemic and subsequent public health emergency (PHE) have propelled telemedicine several years into the future. With the rapid adoption of this technology came socioeconomic inequities as minority communities disproportionately have yet to adopt telemedicine. Telemedicine offers solutions to patient access issues that have plagued urology, helping address physician shortages in rural areas and expanding the reach of urologists. The Centers for Medicare & Medicaid Services have adopted changes to expand coverage for telemedicine services. The expectation is that telemedicine will continue to be a mainstay in the health care system with gradual expansion in utilization.

A Serum C-Reactive Protein and Procalcitonin-Based Risk Score to Predict Urinary Infection in Patients with Obstructive Urolithiasis Undergoing Decompression.

Objective: The aim of this study was to develop a risk score utilizing C-reactive protein (CRP) and procalcitonin to better predict a clinical infection for patients with obstructive urolithiasis. Methods: A retrospective review was performed of patients presenting to the emergency room from December 2017 to February 2019 and who underwent upper urinary tract decompression due to concern for infection in the setting of obstructing urolithiasis. Over 30 clinical parameters were assessed and a composite risk score was created. Univariate and multivariate, forward, stepwise regression analyses were performed to identify predictors of true urinary tract infection (UTI). Results: Ninety-eight patients met inclusion criteria, of which a true UTI was identified in 50 (51%). The standard model of serum white blood cells >15 or temperature >38°C had an area under curve (AUC) of only 0.67 to predict UTI. A multivariable regression-based 4-point risk score (1 point for each of the following: positive urinary Gram stain, perinephric fat stranding on CT, serum CRP >21.95, and serum procalcitonin >0.36) had an AUC of 0.91 to predict UTI. Individually, these components had an AUC of 0.68, 0.68, 0.80, and 0.77, respectively. The chances of confirmed UTI were 8%, 11%, 68%, and 100% for risk scores of 0, 1, 2, and 3 to 4, respectively (p < 0.001). Conclusions: Only 50% of patients with a suspected UTI and an obstructing stone were ultimately confirmed to have a UTI. A risk score consisting of Gram stain, perinephric fat stranding, CRP, and procalcitonin can improve UTI prediction and warrants further study.

Impact of Urology Trainee Debt Levels on Future Practice Choices and Expectations.

INTRODUCTION: Excessive trainee debt continues to be a problem. Little is known about how debt influences future practice decisions. We sought to examine the correlation between educational debt and anticipated practice choices and career expectations to better understand the impact of debt on urology trainees to inform urology workforce policy. METHODS: Data were collected from urology trainees who completed the AUA Annual Census between 2016 and 2018. We examined level of debt among urology trainees against their anticipated practice choices compensation expectation and various debt relief variables. RESULTS: Among 705 U.S. urology trainees who completed the survey, 22% had no debt, 23% had <$150,000 debt, 27% had $150,000 to $250,000 of debt, and the remaining 27% had >$250,000. Debt level did not appear to significantly affect anticipated future practice setting or the decision to pursue fellowship. Concerning how loan forgiveness influenced practice opportunity, 31% of trainees reported no effect, 42% some effect and 27% great effect. Those trainees with higher level of debt appeared to be more likely to accept a practice opportunity if loan forgiveness was offered (p ≤0.001). Those trainees with higher level of debt were more likely to anticipate higher annual compensation as compared to those with less debt (p=0.001). CONCLUSIONS: Nearly 70% of those trainees with debt had $150,000 of debt or higher. Our study showed carrying educational debt is statistically associated with trainees' choice of anticipated practice for better compensation and tuition forgiveness. Workforce policy should consider addressing the financial burden of urology trainees.

Malpractice Litigation in Iatrogenic Ureteral Injury: a Legal Database Review.

OBJECTIVE: To examine the factors associated with iatrogenic ureteral injury litigation and outcomes. METHODS: The Westlaw legal database was queried for all iatrogenic ureteral injury cases. Variables extracted included available clinical factors, method of settlement, and litigation outcomes. Linear regression analysis was conducted to examine factors associated with award amount. RESULTS: A total of 522 cases from 1961 to 2019 were included in the study. The most common specialty named was gynecology (353/512, 68.9%), followed by urology (89/512, 17.4%). The most common claim was intraoperative negligence (474/522 cases, 90.8%). Fifty two cases were settled or arbitrated and 470 went to trial. Settlement or arbitration was more likely in cases involving institution-only defendant (15.4% vs 7.3%, P< .01), academic institution (19.7% vs 7.1%, P < .01), and patient death (42.9% vs 10.7%; P < .001). Of cases that went to trial, the verdict favored the defendant in 339/470 cases (72.1%). The median award was $552,822.96 (interquartile range 187,007-1,063,603). Duration of temporary drainage ($5050/day, P = .02), delayed repair (P = .03), claim of inadequate workup (P = .03), and claim of failure to supervise trainee (P < .001) were significantly associated with increasing award amount. CONCLUSION: The majority of ureteral injury litigation ruled in favor of the defendant. However, when awarded, the amount was substantial and correlated with drainage duration, delayed repair, claim of inadequate workup, and failure to supervise trainee. These findings highlight factors perceived to be associated with significant distress and reflect trends in medicolegal decision-making.

Long-term outcomes of incidental prostate cancer at radical cystectomy.

OBJECTIVE: We evaluated the natural history and long-term outcomes of incidentally detected prostate cancer (PCa) at radical cystectomy (RC) for bladder cancer (BCa). PATIENTS AND METHODS: We identified 1,640 male patients who underwent RC between 1992 and 2012. Patients were stratified as clinically insignificant and clinically significant PCa, based on Grade Group (GG) 1 and ≥2, respectively. Survival was assessed using the Kaplan-Meier method. RESULTS: There were 329 (20%) patients with incidentally detected PCa at RC: 245 (15%) GG1, 52 (3.2%) GG2, 20 (1.2%) GG3, 6 (0.4%) GG4, and 6 (0.4%) GG5. Median follow-up among survivors was 9.6 years (interquartile range 7.5-13.3), during which time 253 patients died, of whom 127 died of BCa and 1 died of PCa. Nine patients experienced biochemical recurrence (BCR), 4 underwent salvage PCa therapies, and 2 developed PCa metastases. Patients with clinically significant PCa were significantly more likely to experience BCR (6% vs. 1.6%; P = 0.04) and had shorter median time to BCR (1.8 vs. 10.4 years; P = 0.01) than those with clinically insignificant PCa. No patients with BCR had greater than pT2N0 BCa or positive BCa margins. Ten-year PCa-specific survival, BCa-specific survival, other cause-specific survival, and overall survival were 99%, 57%, 63%, and 35%, respectively. CONCLUSIONS: In a large RC series, we note a 20% rate of incidental PCa, the majority of which are clinically insignificant. On long-term follow-up, we determined that BCR and PCa mortality are extremely rare events among these patients. Pending validation, future guidelines may consider omission of PCa surveillance for some patients with incidental PCa at RC.

Treatment Outcomes in Patients With Symptomatic Lymphoceles Following Radical Prostatectomy Depend Upon Size and Presence of Infection.

OBJECTIVE: To guide treatment decisions for symptomatic lymphoceles after radical prostatectomy. We examined our experience to create a treatment algorithm. MATERIALS AND METHODS: We evaluated all patients that underwent radical prostatectomy at our institution from 2003 to 2012. Presenting signs, management and treatment outcomes were evaluated. RESULTS: Of the 8081 patients who underwent radical prostatectomy from 2003 to 2012, we identified 123 (1.5%) patients who developed a symptomatic lymphocele, 70 sterile and 53 infected. Percutaneous aspiration was performed in 26 of 123 (21%) patients, of those, 100% recurred. A drain was placed in 86 of 123 (70%) patients for a median of 13 vs 33 days for the infected and sterile lymphocele groups, respectively (P <.001). The median duration of drainage for sterile lymphoceles was 15 vs 58 days for lymphoceles <10 cm vs ≥10 cm (P <.001). Percutaneous drainage was successful in 93% and 86% of patients with infected and sterile lymphoceles, respectively. Laparoscopic unroofing was performed in 18 sterile lymphocele patients (15%) with a success rate of 94%. CONCLUSION: Aspiration of symptomatic lymphoceles should be reserved for diagnostic purposes due to a high risk of recurrence. Infected lymphoceles are optimally treated with drain placement and antibiotics, and have excellent resolution rates. While sterile lymphoceles <10 cm can be successfully managed with drain placement, if drainage and sclerotherapy fail, laparoscopic unroofing should be considered. For patients with sterile lymphoceles ≥10 cm there should be a shared decision-making process to weigh the risk of a protracted course if a drain is utilized vs upfront laparoscopic unroofing.

How to perform a robotic pyeloplasty utilizing the da Vinci SP platform: tips and tricks.

Robotic pyeloplasty has become more prevalent with the evolution and dissemination of robotic surgery. The da Vinci SP robotic platform is a new technology that has allowed for true single port surgery, compared to the previous multiport robotic platforms. As the SP has been utilized for an increasing number of urologic procedures, it can also be successfully used for pyeloplasty. Herein, we describe our technique and tips for performing a da Vinci SP pyeloplasty in the adult population.

Screening Postoperative Hemoglobin after Robot-Assisted Radical Prostatectomy-Frequently Used, but Is It Necessary?

INTRODUCTION: Robot-assisted radical prostatectomy is associated with low rates of postoperative transfusion and hemorrhage. At our institution the decision to obtain screening hemoglobin testing after uncomplicated robot-assisted radical prostatectomy is left to surgeon discretion. It is unknown whether this testing represents high value care. We assessed the prevalence and clinical utility of hemoglobin testing after uncomplicated robot-assisted radical prostatectomy. METHODS: We retrospectively reviewed patients undergoing robot-assisted radical prostatectomy between 2002 and 2016. Patients transfused intraoperatively were excluded. Demographic and perioperative data were reviewed. In patients requiring blood transfusion and/or with hemorrhage clinical signs/symptoms of anemia were reviewed. The primary endpoint was rate of routine postoperative hemoglobin testing. Secondary endpoints included rates of postoperative transfusion and hemorrhage, rates of signs/symptoms of anemia in patients transfused postoperatively and/or with hemorrhage. RESULTS: A total of 3,405 patients were identified of whom 73.8% (2,514) underwent postoperative hemoglobin testing. Mean change relative to preoperative hemoglobin was -2.7±1.0 gm/dl with 10.2% (256) and 3.5% (87) experiencing a decrease in hemoglobin 4 gm/dl or greater and postoperative hemoglobin 10 gm/dl or less, respectively. Of patients undergoing at least 1 postoperative hemoglobin test subsequent testing was prompted for 13.4% (337). Of patients transfused (1.7%, 58) and/or with postoperative hemorrhage (1.5%, 48) with records available for review (46), 95.7% (44) had clinical signs/symptoms of anemia. CONCLUSIONS: Our results suggest that routine hemoglobin testing after uncomplicated prostatectomy should be performed when clinically indicated rather than as routine practice.

Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies.

BACKGROUND: Single-port robotic surgery is being adopted for various surgical procedures. There have been interest in and clinical use of single-port robot-assisted radical prostatectomy (spRARP), but little reported data on feasibility and early outcomes. OBJECTIVE: To describe our institution's initial experience with spRARP utilizing the da Vinci single-port (SP) robotic system. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of the initial experience of three high-volume robotic prostate surgeons performing an spRARP utilizing the da Vinci SP robotic system was carried out. SURGICAL PROCEDURE: An spRARP using the da Vinci SP robotic system was performed following the traditional retropubic or Retzius-sparing approach. MEASUREMENTS: Patient demographics, operative time, blood loss, postoperative hospital stay, complications, and catheter duration were obtained and analyzed. RESULTS AND LIMITATIONS: In a cohort of 49 patients undergoing spRARP, median age was 62yr and prostate-specific antigen 6.4. Of the patients, 35 (71%) had cT1c disease on presentation, 92% had Gleason grade group ≥2 disease, and 85% were pT2 on final pathology. Median operative time was 161min. Median blood loss was 200ml. Seven Retzius-sparing cases were performed. Four Clavien 2 complications occurred (complication rate 8.1%). Median hospital stay was 1d and median catheter duration 7d. Operative time was <200min for all three surgeons by their third case. CONCLUSIONS: The da Vinci SP system spRARP is safe and feasible, with acceptable operative time and blood loss. Further research is needed to establish noninferiority to the da Vinci Xi and Si systems, and impact of spRARP on patient-assessed cosmesis and pain. PATIENT SUMMARY: Robotic prostatectomy using a purpose-built da Vinci single-port robotic system is safe and feasible, and warrants further study to determine whether it can improve patient outcomes.

Comparison of prescribing patterns before and after implementation of evidence-based opioid prescribing guidelines for the postoperative urologic surgery patient.

BACKGROUND: We developed evidence-based guidelines for postoperative opioid prescribing after urologic surgery and assessed changes in prescribing after implementation. METHODS: Prescribing data for adults who underwent 21 urologic procedures were used to derive a four-tiered guideline for postoperative opioid prescribing. This was implemented on January 1, 2018, and prescribing patterns including quantity of opioids prescribed (oral morphine equivalents; OME) and refill rates were compared between patients undergoing surgery prior to (January-April, 2017; n equals 1732) and after (January-April, 2018; n equals1376) implementation. RESULTS: The median OME (IQR) prescribed was significantly lower for 2018 compared with 2017 [100 (0; 175) versus 150 (60; 225); p < .0001]. The median prescribed OME decreased in 14/21 procedures (67%). The refill rates did not significantly change. Guideline adherence rates after implementation, based on individual procedures, ranged from 33 to 95%. CONCLUSIONS: Fewer opioids were prescribed after implementing a prescribing guideline. Additional study is required to assess patient opioid utilization.

Magnet-Assisted Robotic Prostatectomy Using the da Vinci SP Robot: An Initial Case Series.

Introduction: Tissue retraction during minimally invasive surgery has been achieved to date with patient positioning or additional instrumentation. The Levita™ Magnetic Surgical System (San Mateo, CA), a novel, noninvasive, magnetic retraction device for minimally invasive surgery, has been used to facilitate reduced-port robotic prostatectomy using a multiport robotic platform. With the release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA), we now report a multi-institutional initial case series of magnet-assisted robotic prostatectomy using the single-port robotic platform. Materials and Methods: An IRB-approved, retrospective chart review was performed of all patients undergoing robot-assisted radical prostatectomy using the da Vinci SP surgical system and a single Levita magnetic retractor in treatment of prostatic adenocarcinoma at two institutions from November 2018 to January 2019. Preoperative, intraoperative, and postoperative data were collected for descriptive analysis. Results: A total of 15 men, median age 62 years (range 57-71), with mean PSA 7.0 ± 2.3 underwent surgery. The robotic cannula and a single 12-mm assistant port were utilized in all cases, the latter for suction, suture passage, and clip placement; the magnetic retractor aided with posterior dissection, dorsal venous complex stitch placement, bladder neck dissection, and lymphadenectomy. No cases required conversion to a multiport robotic platform, laparoscopy, or open surgery, nor placement of additional assistant ports. No intraoperative or postoperative complications occurred. Average operative time was 224 ± 43 minutes and blood loss was 198 ± 115 mL. All patients were discharged home within 2 days of surgery. Conclusions: Robotic prostatectomy utilizing the da Vinci SP system is feasible, safe, and effective. Use of the magnetic retractor facilitates tissue exposure and improves procedure ergonomics, mimicking the conventional multiport technique. Further exploration of magnet utilization in robotic surgery and optimization of assistant port placement for true single-site surgery is warranted.

Robotic One Access Surgery (R-1): Initial Preclinical Experience for Urological Surgeries.

Laparoendoscopic single-site surgery was developed to minimize the morbidity associated with laparoscopic surgery. Application of robotics in urologic surgery has been widely adopted given the advantages it provides over standard laparoscopy including 3-dimensional vision, improved ergonomics, enhanced precision and dexterity. The real benefit of robotic laparoendoscopic single-site surgery is still unbalanced by the limitations of this approach and the sole applicability by highly skilled surgeons. The ideal robotic platform for single-port surgery should have the possibility of being deployed through a single access site restoring intracorporeal triangulation for precise instrument maneuvers. This manuscript reviews the potential applications of R-1 new surgical robot, highlighting its added value in allowing new surgical approaches.

Evaluation of Medical School Grading Variability in the United States: Are All Honors the Same?

PURPOSE: The medical student performance evaluation (MSPE) summarizes a residency applicant's academic performance. Despite attempts to improve standardized clerkship grading, concerns regarding grade inflation and variability at United States medical schools persist. This study's aim was to describe current patterns of clerkship grading and applicant performance data provided in the MSPE. METHOD: The authors evaluated Electronic Residency Application Service data submitted to a single institution for the 2016-2017 Match cycle. Clerkship grading characteristics regarding grading tiers, school rank, location, and size were obtained. Data regarding methods for summative comparisons such as key word utilization were also extracted. Descriptive statistics were generated, and generalized linear modeling was performed. RESULTS: Data were available for 137/140 (98%) MD-granting U.S. medical schools. Pass/fail grading was most commonly used during the preclinical years (47.4%). A 4-tier system was most common for clerkship grading (31%); however, 19 different grading schemes were identified. A median of 34% of students received the highest clerkship grade (range, 5%-97%). Students attending a top 20 medical school were more likely to receive the highest grade compared with those attending lower-rated schools (40% vs 32%, P < .001). Seventy-three percent of schools ranked students, most commonly using descriptive adjectives. Thirty-two different adjectives were used. CONCLUSIONS: There is significant institutional variation in clinical grading practices and MSPE data. For core clerkships where most students received the highest grade, the ability to distinguish between applicants diminishes. A standardized approach to reporting clinical performance may allow for better comparison of residency applicants.

Impact of time from biopsy to surgery on complications, functional and oncologic outcomes following radical prostatectomy

ABSTRACT Introduction: To determine the impact of time from biopsy to surgery on outcomes following radical prostatectomy (RP) as the optimal interval between prostate biopsy and RP is unknown. Material and methods: We identified 7, 350 men who underwent RP at our institution between 1994 and 2012 and had a prostate biopsy within one year of surgery. Patients were grouped into five time intervals for analysis: ≤ 3 weeks, 4-6 weeks, 7-12 weeks, 12-26 weeks, and > 26 weeks. Oncologic outcomes were stratified by NCCN disease risk for comparison. The associations of time interval with clinicopathologic features and survival were evaluated using multivariate logistic and Cox regression analyses. Results: Median time from biopsy to surgery was 61 days (IQR 37, 84). Median follow-up after RP was 7.1 years (IQR 4.2, 11.7) while the overall perioperative complication rate was 19.7% (1,448/7,350). Adjusting for pre-operative variables, men waiting 12-26 weeks until RP had the highest likelihood of nerve sparing (OR: 1.45, p = 0.02) while those in the 4-6 week group had higher overall complications (OR: 1.33, p = 0.01). High risk men waiting more than 6 months had higher rates of biochemical recurrence (HR: 3.38, p = 0.05). Limitations include the retrospective design. Conclusions: Surgery in the 4-6 week time period after biopsy is associated with higher complications. There appears to be increased biochemical recurrence rates in delaying RP after biopsy, for men with both low and high risk disease.