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.

Young urologists and kidney transplantation training: A survey designed by the French Transplantation Committee of the French Association of Urology (CTAFU) and the French Association of Urologists in training (AFUF).

OBJECTIVE: In France, kidney transplantations (KT) are mainly performed by urologist. Young urologists and residents are involved in this activity mostly performed in emergency. How do they feel about KT training? Is KT an attractive part of the urologist activity? METHODS: This survey has been designed in the form of a questionnaire by the French Committee of Kidney Transplantation (CTAFU) and the French Association of Urologists in training (AFUF). It has been sent by e-mail to all the AFUF members. Interest in KT and performance of the training were evaluated. RESULTS: In total, 126 members filed the form. Among the residents, 51.5% feel secure to perform KT at the end of their residency. KT is considered as an interesting surgery for 92.1% of the participants: 76.5% are willing to get involved in KT during their residency/fellowship. Among the participants, 44% are willing to continue a long-term involvement. Among the residents, 65.9% consider their practical training insufficient: 56.8% have been supervised for a KT performance during their residency and 86% declare a lack of practical training and had a patient-based learning. Among the residents, 92.1% declare an insufficient theorical training. Among the residents, 33.3% say the schedules of transplantation limit their interest in KT. Among the participants, 34.4% receive a transplant bonus in addition to the usual on-call salary. CONCLUSION: Young urologists wish to continue their involvement in KT activity, but improved theoretical and practical training are essential. In addition, the conditions under which this activity is performed and remunerated are a matter of concern.

Gap analysis between trainees' subjective competencies and the competencies expected by instructors in urology: A need assessment survey in Japan.

OBJECTIVE: According to the rapid progress in surgical techniques, a growing number of procedures should be learned during postgraduate training periods. This study aimed to clarify the current situation regarding urological surgical training and identify the perception gap between trainees' competency and the competency expected by instructors in Japan. METHODS: Regarding the 40 urological surgical procedures selected via the Delphi method, we collected data on previous caseloads, current subjective autonomy, and confidence for future skill acquisition from trainees (<15 post-graduate years [PGY]), and the competencies when trainees became attending doctors expected by instructors (>15 PGY), according to a 5-point Likert scale. In total, 174 urologists in Hokkaido Prefecture, Japan were enrolled in this study. RESULTS: The response rate was 96% (165/174). In a large proportion of the procedures, caseloads grew with accumulation of years of clinical practice. However, trainees had limited caseloads of robotic and reconstructive surgeries even after 15 PGY. Trainees showed low subjective competencies at present and low confidence for future skill acquisition in several procedures, such as open cystectomy, ureteroureterostomy, and ureterocystostomy, while instructors expected trainees to be able to perform these procedures independently when they became attending doctors. CONCLUSION: Trainees showed low subjective competencies and low confidence for future skill acquisition in several open and reconstructive procedures, while instructors considered that these procedures should be independently performable by attending doctors. We believe that knowledge of these perception gaps is helpful to develop a practical training program.

Choosing a Specialist: An Explanatory Study of Factors Influencing Patients in Choosing a Urologist.

OBJECTIVES: While research on doctor-patient interaction has often focused on the decision-making abilities of physicians, it rarely centers around the question of how patients choose their respective practitioners. Research on fundamental decision processes is of high importance and understanding the factors that influence people's choices in real-life decision-making would potentially provide patients, and physicians alike, with the means to provide better resources to achieve greater satisfaction from visits to a medical practitioner. METHODS: At our tertiary referral center, patients were given the opportunity to voluntarily participate in our survey. We collected questionnaires from 1,002 patients during their visit from November 2018 to February 2020. Statistical analysis was performed using SPSS V26.0 software (SPSS Statistics, Version 26.0.; IBM, Armonk, NY, USA). Results are reported as percentages for categorial variables. RESULTS: Our patient cohort consisted of a higher percentage of men than of women (82 vs. 18%) with significantly more men having a university-based education (44 vs. 31%; p = 0.001). Women were more likely to have statutory health insurance than men (85 vs. 74%; p = 0.013). Men significantly preferred to be treated by a doctor of the same sex (24 vs. 8%; p < 0.001), which significantly increased with age. Overall, more women than men trusted a referral by their primary care physician (75 vs. 66%, p = 0.017), while preference of a higher academic degree in the attending urologist was significantly correlated with the patients' education. CONCLUSIONS: Information on a specialist, such as professional qualifications and academic accomplishments, is easily accessible to patients with or without access to the Internet. However, recommendations and referrals, in addition to consistent care by the same treating physician, seem to be of high importance to all patients, regardless of gender or age.

Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE: To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. MATERIALS AND METHODS: We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. RESULTS: Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. CONCLUSION: There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Evaluating Quality Improvement and Patient Safety Amongst Practicing Urologists: Analysis of the 2018 American Urological Association Census.

OBJECTIVE: To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation. METHODS: Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload. RESULTS: QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives. CONCLUSION: QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

Adopting Telehealth During The COVID-19 Era: The Urologist's Perspective.

OBJECTIVE: To evaluate the urology providers' (through a range of training levels) experience utilizing telemedicine given the rapid nationwide implementation of telemedicine in urology practices due to COVID-19. Several studies focusing on the patient's perspective have illustrated that telemedicine is comparable to traditional office visits in terms of cost, communication, and overall satisfaction. However, there is sparse data on the provider's experience. METHODS: With IRB approval, we assessed provider satisfaction with telemedicine at Urology programs in the U.S. through an electronic survey. The 25-question survey was based on the Patient Assessment of Communication of Telehealth which is a validated 33 question instrument that has been utilized to assess the quality of patient-provider communication in telemedicine. Experience with telemedicine was assessed in 2 categories: technical aspects and communication with patients. Variables were rated using a 5-point Likert Scale. RESULTS: There were 144 responses to the survey. 50% of providers reported not receiving any formal training in using telemedicine. This differed significantly by training level with 55% of attendings having had received training vs 20% of residents. Providers felt they would most benefit from training in billing (52%) rather than equipment use (33%) or communication (28%). 87% of providers felt comfortable discussing sensitive topics while only 55% felt comfortable using telehealth to schedule surgery (P < .001). CONCLUSION: Urology providers are generally satisfied with their experience communicating with patients via telemedicine and the majority would opt to continue utilizing telemedicine. Nevertheless, many providers are hesitant to schedule surgery via telemedicine. Providers would benefit from formal training in telemedicine.

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.

Understanding the Millennial Physician.

The millennial generation has become the largest generation thus far and continues to grow, as it makes up a substantial part of the workforce. Often misunderstood, those identifying as millennials offer skills, traits, and characteristics that previous generations have been unable to provide. Learning to understand these millennials and all they have to offer serves key to a successful training program or practice. A millennial's understanding of technology, grasp of patient-provider relationships, and desire to work hard contribute to their success as urologists.

Track and Teach: Identifying Key Movement Patterns in Endoscopic Transurethral Enucleation of the Prostate.

PURPOSE: We evaluated a system for noninvasive quantitative motion tracking to recognize differences in the movement pattern of experienced surgeons and beginners. Since performing endoscopic procedures requires extensive training, and tissue damage due to disruptive movements with sudden acceleration is possible, the learning curve for beginners is of clinical relevance. Steepening this curve may improve patient outcome. MATERIALS AND METHODS: We used a commercial gyroscope sensor with a wireless data link, which was attached to the resectoscope handle (RH). After recording, orientation was retrieved by application of the calculated rotation matrices to the RH vector relative to the sensor under the boundary condition of rotational movement around and quasi-constant distance to the pivot point at pelvic floor level. Data alignment, normalization, interpolation, and analysis were performed in custom software scripts. RESULTS: Experienced surgeons and beginners were recorded in n = 36 and n = 14 holmium laser enucleation of the prostate (HoLEP), respectively. Prostate size, patient age, and recorded procedure duration were comparable. Mean lever angle of the individual normalized motion patterns was considerably lower (19.28 ± 0.54° [SEM]) in the advanced than in the beginners' group (24.52 ± 1.00°; p = 0.0001). Further parameters such as velocity and motion variation demonstrated additional differences between both groups. CONCLUSIONS: We demonstrate the feasibility of motion tracking in HoLEP. Pronounced differences exist between different stages of surgeon experience with this procedure. The method can easily be adopted to aide young surgeons in resectoscope handling and identification of improvable motion patterns. Damage to the pelvic floor and surrounding tissue may thus be reduced.

Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns.

OBJECTIVE: To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists. METHODS: Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns. RESULTS: As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked "What is most challenging about HoLEP in current practice?" common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm). CONCLUSION: With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

Impact of COVID-19 on medical education: introducing homo digitalis.

PURPOSE: To determine how members of the Société Internationale d'Urologie (SIU) are continuing their education in the time of COVID-19. METHODS: A survey was disseminated amongst SIU members worldwide by email. Results were analyzed to examine the influence of age, practice region and settings on continuing medical education (CME) of the respondents. RESULTS: In total, 2494 respondents completed the survey. Internet searching was the most common method of CME (76%; all ps < 0.001), followed by searching journals and textbook including the online versions (62%; all ps < 0.001). Overall, 6% of the respondents reported no time/interest for CME during the pandemic. Although most urologists report using only one platform for their CME (26.6%), the majority reported using ≥ 2 platforms, with approximately 10% of the respondents using up to 5 different platforms. Urologists < 40 years old were more likely to use online literature (69%), podcasts/AV media (38%), online CME courses/webinars (40%), and social media (39%). There were regional variations in the CME modality used but no significant difference in the number of methods by region. There was no significant difference in responses between urologists in academic/public hospitals or private practice. CONCLUSION: During COVID-19, urologists have used web-based learning for their CME. Internet learning and literature were the top frequently cited learning methods. Younger urologists are more likely to use all forms of digital learning methods, while older urologists prefer fewer methods.

Challenges in Urology during the COVID-19 Pandemic.

The COVID-19 pandemic has caused a global health threat. This disease has brought about huge changes in the priorities of medical and surgical procedures. This short review article summarizes several test methods for COVID-19 that are currently being used or under development. This paper also introduces the corresponding changes in the diagnosis and treatment of urological diseases during the COVID-19 pandemic. We further discuss the potential impacts of the pandemic on urology, including the outpatient setting, clinical work, teaching, and research.

Pentosan Polysulfate Maculopathy: What Urologists Should Know in 2020.

OBJECTIVE: To conduct a review of current literature to assess whether an association exists between Pentosan Polysulfate Sodium and the development of macular disease, as it is the only oral medication approved by the Food and Drug Administration for the management of interstitial cystitis. MATERIALS AND METHODS: A systematic review was conducted by the authors separately, with review methods established prior to the conduct of the review. Databases searched included PubMed, Ovid, Medline, EBSCO, and Google Scholar. A search was conducted for the terms "Pentosan Polysulfate Maculopathy," "Pentosan Polysulfate Retinopathy," and "Interstitial Cystitis Maculopathy." All papers reporting on primary data were included. There were no study sponsors. RESULTS: A total of 14 papers reporting on primary data were identified. Most papers reported on the development of macular disease in the setting of chronic pentosan polysulfate sodium exposure. No randomized controlled trials have been performed to date and data was insufficient to perform a meta-analysis. Nevertheless, patients with interstitial cystitis were more likely to receive a diagnosis of maculopathy after several years of the medication use. CONCLUSION: Although the nature of the published studies renders them prone to confounders, currently available data suggest an increased risk for developing maculopathy after years of pentosan polysulfate sodium use. In light of this, and the marginal effectiveness of the medication for the average individual, we suggest that education be provided as to the possible association and that regular ophthalmic evaluation be recommended for patients who are continued on chronic Pentosan Polysulfate Sodium.

Assessment of Advanced Perioperative Outcomes to Identify the True Learning Curve of Robotic-assisted Partial Nephrectomy.

OBJECTIVES: To evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL). METHODS: We evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR). RESULTS: Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m2 (interquartile range 26-33). Surgeon experience was associated with shorter OT (-2.5% per 50% increase in case number; 95% confidence interval; P <.001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P = .086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33). CONCLUSION: There does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases.