Mitigating Contaminant-Driven Risks for the Safe Expansion of the Agricultural-Sanitation Circular Economy in an Urbanizing World.

The widespread adoption of an agricultural circular economy requires the recovery of resources such as water, organic matter, and nutrients from livestock manure and sanitation. While this approach offers many benefits, we argue this is not without potential risks to human and environmental health that largely stem from the presence of contaminants in the recycled resources (e.g., pharmaceuticals, pathogens). We discuss context specific challenges and solutions across the three themes: (1) contaminant monitoring; (2) collection transport and treatment; and (3) regulation and policy. We advocate for the redesign of sanitary and agricultural management practices to enable safe resource reuse in a proportionate and effective way. In populous urban regions with access to sanitation provision, processes can be optimized using emergent technologies to maximize removal of contaminant from excreta prior to reuse. Comparatively, in regions with limited existing capacity for conveyance of excreta to centralized treatment facilities, we suggest efforts should focus on creation of collection facilities (e.g., pit latrines) and decentralized treatment options such as composting systems. Overall, circular economy approaches to sanitation and resource management offer a potential solution to a pressing challenge; however, to ensure this is done in a safe manner, contaminant risks must be mitigated.

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.

Maximum Covering Subtrees for Phylogenetic Networks.

Tree-based phylogenetic networks, which may be roughly defined as leaf-labeled networks built by adding arcs only between the original tree edges, have elegant properties for modeling evolutionary histories. We answer an open question of Francis, Semple, and Steel about the complexity of determining how far a phylogenetic network is from being tree-based, including non-binary phylogenetic networks. We show that finding a phylogenetic tree covering the maximum number of nodes in a phylogenetic network can be computed in polynomial time via an encoding into a minimum-cost flow problem.

Workforce Characteristics in Urology.

INTRODUCTION: In this study we holistically describe and characterize the current state of urology practice by evaluating compensation, workload and practice factors as they relate to our demographic makeup as a specialty. METHODS: We collaborated with the American Urological Association to query its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. The survey consisted of 26 questions and took approximately 13 minutes to complete. A total of 733 responders had complete data for the factors statistically analyzed in the study. RESULTS: Mean yearly compensation for urologists surveyed was $404,755 and median compensation was $380,000 (IQR $300,000-480,000). Female respondents had a significantly lower median yearly compensation vs males ($318,422 vs $400,000) on univariate and multivariate analysis. Respondents reported a median of 60 work hours per week (IQR 50-60) and the median number of call days per month was 7 (IQR 5-10). Of the respondents 62% indicated that they use advanced practice providers in their practice. In addition, 30% reported employed status, 49% reported self-employed status and 21% reported academic status. Overall 20% of respondents plan to retire within 5 years and 40% within 10 years. CONCLUSIONS: Higher income was associated with greater job satisfaction and hourly wage appeared to decrease at increased work hours per week. Several workplace and demographic factors drive compensation, number of hours worked per week, number of call days per month and job satisfaction.

Burnout in Urology: Findings from the 2016 AUA Annual Census.

INTRODUCTION: Physician burnout is linked to decreased job performance, increased medical errors, interpersonal conflicts and depression. Two recent multispecialty studies showed that urologists had the highest rate of burnout. However, these reports were limited by a low sample size of urologists (119). We aimed to establish the prevalence of urologist burnout and associated factors. METHODS: In the 2016 American Urological Association Census, Maslach Burnout Inventory questions were randomly assigned to half of the respondents. Using matrix sampling, the 1,126 practicing urologists who received and answered the Maslach Burnout Inventory questions represented the entire 2,301 who completed the census. Burnout was defined as scoring high on the scales of emotional exhaustion or depersonalization. Demographic and practice variables were assessed to establish factors correlating to burnout. RESULTS: Overall 38.8% of urologists met the criteria for burnout, with 17.2% scoring high for emotional exhaustion and 37.1% scoring high for depersonalization. Multivariate analysis revealed that urologist burnout is associated with more patient visits per week, younger age, being in a subspecialty area other than pediatric or oncology, in solo or multispecialty practice, practice size greater than 2 and greater number of work hours per week. CONCLUSIONS: These results suggest that the burnout rate for urologists is lower than previously reported, and are consistent with rates reported in other medical and surgical specialties. However, burnout continues to be an important issue. Greater workload correlated with increased burnout while other practice patterns appeared to be protective. It is critical to keep urologists in the workforce to help lessen projected shortages.

Minimally invasive surgery in adult degenerative scoliosis: a systematic review and meta-analysis of decompression, anterior/lateral and posterior lumbar approaches.

BACKGROUND: Minimally invasive approaches for the treatment of adult degenerative scoliosis have been increasingly implemented. However, little data exists regarding the safety and complication profiles of minimally invasive lumbar interbody fusion (LIF) for adult degenerative scoliosis. This study aimed to greater understand different minimally invasive surgical approaches for adult degenerative scoliosis with respect to clinical outcomes, changes in radiographic measurements, and complication profiles via meta-analytical techniques. METHODS: A systematic search of six databases from inception to September 2015 was performed by two independent reviewers. Relevant studies were those that described the safety and/or effectiveness of minimally invasive anterior or lateral LIF (LLIF), transforaminal LIF (TLIF), and decompression only. Meta-analytical techniques and meta-regression were used to pool overall rates, and compare the different techniques. There was no financial funding or conflict of interest. RESULTS: A total of 29 studies (1,228 patients) were included in this meta-analysis. Total pooled fusion rate was 95.9% (95% CI: 92.7-98.2%) for the anterior/lateral approach. The pooled construct or hardware-related complications was 4.3%, and was similar among anterior/lateral (4.4%) and posterior (5.2%) techniques. The total pooled pseudoarthrosis rate was 4.3% for the lateral approach. The overall pooled rate of motor deficit was 2.7% (95% CI: 1.7-4.0%). Subgroup meta-regression demonstrated that the anterior/lateral approach had the highest rate of motor deficits (3.6% LLIF vs. 0.7% TLIF vs. 0.5% decompression, P=0.004). The overall pooled rate of sensory deficit was 2.4%, highest for the anterior/lateral technique (3.3%) compared to TLIF (0.7%) and decompression (0.5%). The infection rate, dural tears/CSF leak, cardiac and pulmonary events were similar among the techniques, with a pooled value of 2.6%, 3.9%, 1.7%, and 1.4%, respectively. Similarly satisfactory radiological outcomes were obtained amongst the different approaches. CONCLUSIONS: Minimally invasive spine technologies may be used for the surgical treatment of lumbar degenerative scoliosis with acceptable complication rates, functional and radiological outcome. Future studies, specifically multi-centered longitudinal, examining the adequacy of minimally invasive spine surgery is warranted to compare long-term outcomes with the traditional procedure.

Urinary tract infections in children with prenatal hydronephrosis: A risk assessment from the Society for Fetal Urology Hydronephrosis Registry.

INTRODUCTION: Risk factors for urinary tract infection (UTI) in children with prenatal hydronephrosis (PNH) are not clearly defined. Our study aim was to describe incidence and identify factors associated with UTI among a cohort of children diagnosed with PNH. MATERIAL AND METHODS: Patients with confirmed PNH from four medical centers were prospectively enrolled in the Society for Fetal Urology (SFU) hydronephrosis registry between 9/2008 and 10/2015. Exclusion criteria included enrollment because of UTI, associated congenital anomalies, and less than 1-month follow-up. Univariate analysis was performed using Fisher's Exact test or Mann-Whitney U. Probability for UTI was determined by Kaplan-Meier curve. RESULTS: Median follow-up was 12 (IQR 4-20) months in 213 patients prenatally diagnosed with hydronephrosis. The majority of the cohort was male (72%), Caucasian (77%), and 26% had high grade (SFU 3 or 4) hydronephrosis. Circumcision was performed in 116/147 (79%) with known status, 19% had vesicoureteral reflux (VUR), and 11% had ureteral dilatation. UTI developed in 8% (n = 18), 89% during their first year of life. Univariate analysis found UTI developed more frequently in females (p < 0.001), uncircumcised males (p < 0.01), and the presence of parenchymal renal cyst (p < 0.05). Logistic regression found renal cyst to no longer be significant, but female gender a significant risk factor for development of UTI (p < 0.001). Regression analysis stratified by gender found neither hydronephrosis grade nor parenchymal renal cyst to be significant risk factors for UTI development among females. However, hydronephrosis grade and circumcision status were significant risk factors for development of UTI among males (p < 0.05 and p < 0.01, respectively). CONCLUSION: Identification of factors associated with UTI in patients with PNH is still progressing; however, several observational studies have identified groups that may be at increased risk of UTI. Use of prophylactic antibiotics (PA), degree of kidney dilation, gender, and circumcision status all have been reported to have some degree of impact on UTI. A previous study identified risk factors for UTI as female gender, uncircumcised status, hydroureteronephrosis, and VUR, and reported that prophylaxis provided a protective effect on prevention of UTI. Our data mirror those in some respect, identifying an association of UTI with female gender and, among males, uncircumcised status, and high grade hydronephrosis. However, we were unable to demonstrate an association between UTI and the use of PA, presence of VUR, dilated ureter, or renal duplication in this observational registry.

The Near-future Impact of Retirement on the Urologic Workforce: Results From the American Urological Association Census.

OBJECTIVE: To assess self-perceived planned retirement patterns among urologists by using the American Urological Association Census Data. With an expanding elderly population and an aging urologic workforce, concerns regarding increased demand and decreased supply of urologists have been raised. MATERIALS AND METHODS: We analyzed data from the 2014 American Urological Association Census, which is a specialty representative survey distributed to the urologists who practice in the United States. A total of 2204 census samples were weighted to represent 11,703 urologists who practiced in the United States in 2014. We compared urologists who are nearing retirement (within 5 years of their planned retirement) with the rest of urologists on their demographic, geographic, and practice characteristics. RESULTS: Of the 11,703 practicing urologists in the United States, 3181 (95% confidence interval: 2884-3479) or 27% (95% confidence interval: 25%-30%) are nearing planned retirement. The mean age (standard deviation [SD]) of urologists nearing retirement (69, SD = 8.2) was older than nonretiring urologists (48, SD = 10.3), P < .01. Nearly double the proportion of nearing retirement urologists is found in nonmetropolitan compared to nonretiring urologists, 534 (17%) vs 782 (9%), P < .01, respectively. Urologists nearing retirement are more likely to practice general urology compared to nonretiring urologists, 2341 (74%) vs 5072 (60%), P < .01. Among urologists nearing retirement, 2155 (68%) of them still perform inpatient operations. CONCLUSION: More than one-fourth of existing practicing urologists plan to retire in the next 5 years. General urology and urology practices outside of metropolitan areas will be impacted the most by the planned retiring workforce.

Focusing on organ preservation and function: paradigm shifts in the treatment of pediatric genitourinary rhabdomyosarcoma.

OBJECTIVE: Pediatric genitourinary rhabdomyosarcoma (RMS) accounts for 25 % of all pediatric soft tissue sarcomas. The treatment of these tumors has shifted over time from debilitating radical exenteration to organ-sparing techniques using multimodal therapy. Our review aims to summarize recent relevant literature regarding the current treatment practices of pediatric genitourinary RMS and how these practices have shifted over time. METHODS: PubMed database search was utilized to identify relevant literature from 1997 to 2015 relating to the treatment of pediatric genitourinary RMS with emphasis on organ preservation and maintaining organ function. RESULTS: A total of 31 articles from 1997 through 2015 were identified relating to current management concepts in pediatric genitourinary sarcomas. Relevant articles were reviewed in detail and discussed. CONCLUSION: The treatment of pediatric genitourinary RMS has shifted from debilitating pelvic exenteration to a multimodal treatment approach involving surgery, chemotherapy, and radiation therapy in an effort to preserve genitourinary organs and reduce treatment morbidity. Continued research is required to improve post-treatment organ function. Further studies utilizing objective urodynamic evaluation are necessary to better characterize bladder function after treatment for RMS. Exciting recent developments in RMS research of fusion proteins that induce cell transformation and inhibit apoptosis and myogenic differentiation may result in future management changes to treatment protocols.

Factors Related to Job Satisfaction in Urology.

INTRODUCTION: There is little information on job satisfaction in the extant literature in urology. The purpose of this study is to examine 1) the current state of job satisfaction among urologists in the United States, and 2) the demographic and work place factors that have the greatest influence on satisfaction. METHODS: We collaborated with AUA (American Urological Association) to query its domestic membership of practicing urologists regarding socioeconomic, work force and quality of life issues. A total of 848 responses were collected for a total response rate of 13%. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction scores on a 1 to 5 scale. RESULTS: Of providers 70% reported being satisfied, 63% reported that they would choose medicine again and 83% would choose urology again. Age and job satisfaction did not demonstrate a linear association on statistical analysis but rather a U-shaped relationship. On bivariate analysis significant factors associated with higher job satisfaction included younger and older age, higher income (p = 0.047), fewer call days (p = 0.006), fellowship training (p = 0.006) and academic practice (overall p = 0.002). On multivariate analysis age (younger and older ages) and academic practice remained significant predictors of job satisfaction (p = 0.01) as did higher income (p = 0.038). CONCLUSIONS: The current study helps describe the current state of job satisfaction among American urologists and examined work place factors that influence satisfaction. Income, hours worked, academic practice and age each have a significant impact on job satisfaction for the practicing urologist. Keeping abreast of the drivers of job satisfaction is critical to ensure that urologists continue to care for patients, perform research, educate future physicians and provide service to their communities.

Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology.

PURPOSE: The proportion of women in urology has increased from less than 0.5% in 1981 to 10% today. Furthermore, 33% of students matching in urology are now female. In this analysis we characterize the female workforce in urology compared to that of men with regard to income, workload and job satisfaction. MATERIALS AND METHODS: We collaborated with the American Urological Association to survey its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. A total of 6,511 survey invitations were sent via e-mail. The survey consisted of 26 questions and took approximately 13 minutes to complete. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction and compensation. RESULTS: A total of 848 responses (660 or 90% male, 73 or 10% female) were collected for a total response rate of 13%. On bivariable analysis female urologists were younger (p <0.0001), more likely to be fellowship trained (p=0.002), worked in academics (p=0.008), were less likely to be self-employed and worked fewer hours (p=0.03) compared to male urologists. On multivariable analysis female gender was a significant predictor of lower compensation (p=0.001) when controlling for work hours, call frequency, age, practice setting and type, fellowship training and advance practice provider employment. Adjusted salaries among female urologists were $76,321 less than those of men. Gender was not a predictor of job satisfaction. CONCLUSIONS: Female urologists are significantly less compensated compared to male urologists after adjusting for several factors likely contributing to compensation. There is no difference in job satisfaction between male and female urologists.

Complexity in the diagnosis and management of 45,X Turner Syndrome mosaicism.

Diagnosis, decision making, and counseling for patients with disorders of sexual development pose challenges for physicians and families. Accurate antenatal evaluation combined with effective communication between the family and multidisciplinary team is important to provide the best patient outcome. We reviewed 2 cases from our institution that illustrate the complexity of antenatal and postnatal management in Turner Syndrome patients who have 45,X mosaicism. We concluded that because of the complexity involved in providing appropriate care to these individuals, it is critical that accurate and universally accessible counseling materials are available to providers and families at the time of diagnosis and management decision making.

Challenges facing academic urology training programs: an impending crisis.

OBJECTIVE: To determine the most pressing issues facing academic urology training centers. The supply of urologists per capita in the United States continues to decrease. Stricter resident requirements, restriction of resident duty hours, and a Graduate Medical Education (GME) funding cap on resident education has led to significant challenges for academic centers. METHODS: A 32-question survey was sent to Society of University Urologists members. Respondents defined themselves as academic faculty tenure track, program director, academic chair, program director and academic chair, clinical faculty nontenure track, and community faculty member. RESULTS: A total of 143 of 446 members(32%) responded. A lack of funding was indicated as an obstacle to adding new residency positions (65% respondents) and recruiting new faculty (60% respondents). Residency positions not funded by GME (40% respondents) required either clinical or hospital dollars to support these slots. Most respondents (51%) indicated resident research rotations are funded with clinical dollars. Surgical skills laboratories are commonly used (85% respondents) and are supported mostly with hospital or clinical dollars. The majority of respondents (84%) indicated they would expand simulation laboratories if they had better funding. Other than urodynamics and ultrasound, urology residency training programs reported little income from ancillary dollars. CONCLUSION: There is a significant workforce shortage within urology training programs. Clinical revenue and hospital funding seem to be the main financial support engines to supplement the GME funding shortage, proficiency training, and faculty salary support for teaching. The current system of GME funding for urology residency programs is not sustainable.

Urethral mobilization for distal and mid shaft hypospadias with chordee.

PURPOSE: Many options are available for repairing mid shaft to distal hypospadias. Reported complications include poor cosmesis, persistent chordee, meatal stenosis and fistula. We hypothesized that advancing the intact native urethra would facilitate chordee correction and minimize complications. MATERIALS AND METHODS: We retrospectively reviewed our records of all 248 hypospadias repairs done from July 2003 to May 2009 and identified patients younger than 18 years with distal or mid shaft hypospadias who underwent repair by urethral mobilization. The outcomes recorded were patient satisfaction, bladder scan volume, and the rate of fistula, meatal stenosis or other complications. RESULTS: Of the patients 83 met study inclusion criteria, including 5 (6%) treated with previous failed hypospadias operations. The hypospadias site was the distal, mid shaft and megameatal intact prepuce variant in 69 (83.1%), 11 (13.3%) and 3 patients (3.6%), respectively. Chordee was present in 80 patients (96.4%). The mean degree of chordee was 61.5 degrees, mean age at operation was 35.7 months and mean followup was 18 months (range 0.25 to 79). Of parental responses 94% were pleased or very pleased. Mean bladder volume on bladder scan was 9.7 ml (range 0 to 81). Fistula developed in 1 patient (1.2%). There were no meatal stenosis cases. CONCLUSIONS: Urethral mobilization results in excellent cosmesis and a low complication rate. This technique is especially well suited to patients with prior operations or deficient preputial skin. Using the native urethra with its blood supply is our preferred method of repairing distal and mid shaft hypospadias with chordee.