Practice Readiness? Trends in Chief Resident Year Training Experience Across 13 Residency Programs.

INTRODUCTION: Urology residency prepares trainees for independent practice. The optimal operative chief resident year experience to prepare for practice is undefined. We analyzed the temporal arc of cases residents complete during their residency compared to their chief year in a multi-institutional cohort. METHODS: Accreditation Council for Graduate Medical Education case logs of graduating residents from 2010 to 2022 from participating urology residency programs were aggregated. Resident data for 5 categorized index procedures were recorded: (1) general urology, (2) endourology, (3) reconstructive urology, (4) urologic oncology, and (5) pediatric urology. Interactions were tested between the trends for total case exposure in residency training relative to the chief resident year. RESULTS: From a sample of 479 resident graduates, a total of 1,287,433 total cases were logged, including 375,703 during the chief year (29%). Urologic oncology cases had the highest median percentage completed during chief year (56%) followed by reconstructive urology (27%), general urology (24%), endourology (17%), and pediatric urology (2%). Across the study period, all categories of cases had a downward trend in median percentage completed during chief year except for urologic oncology. However, only trends in general urology (slope of -0.68, P = .013) and endourology (slope of -1.71, P ≤ .001) were significant. CONCLUSIONS: Over 50% of cases completed by chief residents are urologic oncology procedures. Current declining trends indicate that residents are being exposed to proportionally fewer general urology and endourology cases during their chief year prior to entering independent practice.

Navigating the Ophthalmology & Urology Match with a Significant Other.

OBJECTIVE: Medical students with a significant other in medical school face challenges when applying for residency as they attempt to match in proximity to their partner. The National Resident Matching Program (NRMP) offers a Couples Match to aid such applicants. This system is not available for ophthalmology and urology because these specialties utilize match systems outside the NRMP and have an early match timeline. The purpose of this study is to analyze usage of the Couples Match and assess ophthalmology and urology applicant viewpoints on the Couples Match system. DESIGN & SETTING: First, NRMP data on the Couples Match from 1987 to 2021 was reviewed. Second, an online survey was sent to 559 ophthalmology and 321 urology applicants to The Johns Hopkins University School of Medicine in the 2021 match cycle. PARTICIPANTS: 342 ophthalmology and urology applicants (39% response rate). RESULTS: There is increased usage of the Couples Match over time. In response to the survey, 89% of participants agreed that a Couples Match should be implemented in their specialty. 107 (31%) had a significant other in medicine. 78% of 68 respondents whose significant other also applied in 2021 reported that they would have used the Couples Match had it been available. 21% of those with a significant other considered not applying to ophthalmology or urology because there was no Couples Match. There are mixed responses regarding whether the early match timeline is beneficial to couples. Female applicants were more likely to report hesitancy about mentioning a significant other during the application process. CONCLUSIONS: The Couples Match is highly desired by applicants to ophthalmology and urology, and the lack of such a system is a deterrent to pursuing these fields. Future studies will help elucidate how the match system can be leveraged to aid individuals applying with a significant other.

Surgical ergonomics for urologists: a practical guide.

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

Inaccuracies in News Media Reporting About the 2019 US Food and Drug Administration Ban on Transvaginal Mesh for Pelvic Organ Prolapse Repair.

OBJECTIVE: To analyze inaccuracies in the news media reporting of the 2019 US Food and Drug Administration (FDA) ban on surgical mesh for transvaginal repair of pelvic organ prolapse (POP). METHODS: We queried the NexisUni media database for English-language news articles about "transvaginal mesh" or "FDA" published before and after the ban. Content analysis was based on discussion of the ban, indications for surgical mesh, and assessment of bias. We characterized public interest in transvaginal mesh using Google Trends. RESULTS: Of 290 news articles reviewed, 42 articles were included for analysis. Public interest in transvaginal mesh increased 4-fold after the FDA announcement. While 15 articles (38%) accurately reported that mesh was used in both POP and incontinence repairs, a plurality (18, 43%) only described using mesh for POP. The majority (30, 71%) of articles did not specify that the FDA ban applied to only transvaginal repair of POP and not to incontinence. Despite multiple professional societies affirming the use of mesh for incontinence, only 2 (5%) articles cited these evidence-based recommendations. About half of the articles had an overtly biased tone; articles with an anti-mesh bias were significantly less likely to identify the mesh indications relevant to the ban (P <.01). CONCLUSION: Seventy percent of news reports about the 2019 FDA ban on transvaginal mesh for POP failed to distinguish between the clinical indications for mesh impacted by the ban. The findings raise concern about patient perceptions of and future access to mesh surgery, regardless of indication.

Application Factors May Not Be Predictors of Success Among General Surgery Residents as Measured by ACGME Milestones.

BACKGROUND: Can factors within the Electronic Residency Application Service application be used to predict the success of general surgery residents as measured by the Accreditation Council for Graduate Medical Education (ACGME) general surgery milestones? METHODS: This is a retrospective study of 21 residents who completed training at a single general surgery residency program. Electronic Residency Application Service applications were reviewed for objective data, such as age, US Medical Licensing Examination scores, and authorship of academic publications as well as for letters of recommendation, which were scored using a standardized grading system. These factors were correlated to resident success as measured by ACGME general surgery milestone outcomes using univariate and multivariate analyses. This study was conducted at a single academic tertiary care and level 1 trauma facility. Residents who completed general surgery residency training from the years of 2012-2018 were included in the study. RESULTS: There were few correlations between application factors and resident success determined by the ACGME milestones. CONCLUSIONS: Application factors alone do not account for ongoing growth and development throughout residency. Unlike the results presented in the literature for other surgical subspecialties, predicting general surgery resident success based on application factors is not straightforward.

Primary small cell carcinoma of the upper urinary tract: A case report.

Small cell carcinoma of the urinary tract is an aggressive malignancy that comprises less than 1% of urinary bladder cancers. The renal pelvis and ureter, also lined by urothelium, are rare sites for small cell carcinoma. The diagnosis and staging of upper tract cancer are difficult due to the need for small, atraumatic instrument to access the upper tract. There are fewer than 40 reported cases of upper urinary tract small cell carcinoma. These include both pure and variant histologies. We present the management of a 72 year old male with small cell carcinoma of the upper urinary tract.

Metastatic urothelial carcinoma to the liver with unknown primary tumor.

Cancer of unknown primary (CUP), a rare and aggressive clinical entity, accounts for approximately 3% of all malignancies. CUP with urothelial origin is even more unusual, with no other cases reported in the current literature. As imaging and other studies often do not reveal the tumor origin, the approach to CUP involves a focused search for the primary tumor, relying on guidance from immunohistochemical staining of biopsy specimens. Treatment consists of standard therapies directed at the most likely tumor origin.

Metastatic clear cell renal cell carcinoma to the forearm without identifiable primary renal mass.

Kidney cancer is the ninth most common malignancy in the United States. Most kidney cancers are clear cell renal cell carcinoma (RCC) and arise as solid tumors from kidney parenchyma. In the setting of metastatic disease, a primary renal tumor is usually identified, and metastases are often to lung, bone, liver, and brain. Metastatic RCC without an identifiable solid kidney tumor is exceedingly rare. We report the case of a 52 year old male with a rare cutaneous RCC metastasis without an identifiable primary renal tumor.

Perioperative management of cold agglutinin autoimmune hemolytic anemia in an older adult undergoing radical cystectomy for bladder cancer.

Patients diagnosed with bladder cancer are most frequently older adults who have multiple chronic conditions. Frequently, new conditions are unmasked during preoperative evaluation for surgery such as radical cystectomy. We report the case of an 85 year old male with muscle invasive bladder cancer who was concurrently diagnosed with cold agglutinin hemolytic anemia. This case demonstrates the importance of close attention to underlying chronic conditions in older adults considering major cancer surgery and the need for multidisciplinary management in medically complex cases.

Impact of Age and Comorbidities on Use of Sacral Neuromodulation.

PURPOSE: We investigated the influence of patient age on sacral nerve stimulation trial outcomes, device implantation and treatment durability. MATERIALS AND METHODS: We analyzed a database of all sacral nerve stimulation procedures performed between 2012 and 2014 at a high volume institution for associations of patient age with sacral nerve stimulation indication, trial stimulation success, device revision and device explantation. RESULTS: In a cohort of 356 patients those with nonobstructive urinary retention and urgency-frequency were younger than patients with urgency urinary incontinence. Trial stimulation success did not differ by age in stage 1 and percutaneous nerve evaluation trials (p = 0.51 and 0.84, respectively). Logistic regression identified greater odds of trial success in females compared to males (OR 2.97, 95% CI 1.32-6.04, p = 0.009) and for urgency urinary incontinence compared to urgency-frequency (OR 3.02, 95% CI 1.39-6.50, p = 0.006). In analyzed patients there were 119 surgical revisions, including battery replacement, and 53 explantations. Age was associated with a decreased risk of revision with 3% lower odds per each additional year of age (OR 0.97, 95% CI 0.95-0.98, p <0.0001). While age did not influence explantation, for each body mass index unit there was a 5% decrease in the odds of explantation (OR 0.95, 95% CI 0.91-0.98). CONCLUSIONS: In contrast to previous studies, older patients experienced no difference in the sacral nerve stimulation response in stimulation trials and no difference in the implantation rate. Furthermore, age was modestly protective against device revision. This suggests that age alone should not negatively predict sacral nerve stimulation responses.

Transvaginal sling excision: tips and tricks.

INTRODUCTION AND HYPOTHESIS: Complications of synthetic midurethral sling surgery include bladder outlet obstruction, mesh extrusion, and vaginal pain. A treatment of these complications is transvaginal mesh removal. The objectives of this video are to present cases of complications after sling placement and describe techniques to help with successful sling removal. METHODS: Three patients are presented in this video. One experienced urinary hesitancy and was found to have bladder outlet obstruction on urodynamic study. The second patient presented to the clinic with diminished force of stream and significant dyspareunia. The last patient presented with mesh extrusion. After discussion of management options, all three patients wished to pursue transvaginal sling excision. RESULTS: All patients had successful removal of a portion of their synthetic midurethral sling. This video presents techniques to aide with dissection, mesh excision and prevention of further mesh complications. These include using an individualized surgical technique based on patient presentation and surgeon expertise, planning surgical incisions based on where mesh can be identified or palpated, using a cystoscope sheath or urethral dilator to identify any bladder outlet obstruction, and using a knife blade to identify mesh from surrounding tissue. CONCLUSIONS: Sling excision can be successfully performed with careful surgical technique and dissection.

Urethrovaginal fistula closure.

INTRODUCTION AND HYPOTHESIS: In the developed world, urethrovaginal fistulas are most the likely the result of iatrogenic injury. These fistulas are quite rare. Proper surgical repair requires careful dissection and tension-free closure. The objective of this video is to demonstrate the identification and surgical correction of an urethrovaginal fistula. METHODS: The case presented is of a 59-year-old woman with a history of pelvic organ prolapse and symptomatic stress urinary incontinence who underwent vaginal hysterectomy, anterior colporrhaphy, posterior colporrhaphy, and synthetic sling placement. Postoperatively, she developed a mesh extrusion and underwent sling excision. After removal of her synthetic sling, she began to experience continuous urinary incontinence. Physical examination and cystourethroscopy demonstrated an urethrovaginal fistula at the midurethra. Options were discussed and the patient wished to undergo transvaginal fistula repair. RESULTS: The urethrovaginal fistula was intubated with a Foley catheter. The fistula tract was isolated and removed. The urethra was then closed with multiple tension-free layers. This video demonstrates several techniques for identifying and subsequently repairing an urethrovaginal fistula. Additionally, it demonstrates the importance of tension-free closure. CONCLUSIONS: Urethrovaginal fistulas are rare. They should be repaired with careful dissection and tension-free closure.

Treatment of vaginal stenosis with fasciocutaneous Singapore flap.

INTRODUCTION: Vaginal stenosis is an unfortunate complication that can occur after pelvic radiation therapy for gynecologic or colorectal malignancies. Treatment is challenging and can require significant reconstructive surgery. The objective of this video is to present a case of vaginal stenosis after radiation and describe vaginal reconstruction with a fasciocutaneous Singapore flap. METHODS: We describe the case of a 42-year-old woman with a history of stage 3 colorectal cancer who underwent partial colectomy, chemotherapy, and pelvic radiation. She subsequently developed a rectovaginal fistula requiring repair with a right-sided gracilis flap. When her stenosis recurred, she underwent vaginal reconstruction with a medial thigh flap. RESULTS: The Singapore flap is a pudendal thigh flap centered on the labial crural fold with a base at the perineal body. As the cutaneous innervation is spared, this flap is sensate. This technique is one option for patients with complex vaginal stenosis who have failed conservative management. However, it is imperative the patient perform vaginal dilation postoperatively and maintain close follow-up with her surgeon, as vaginal stenosis can recur. CONCLUSIONS: Postradiation vaginal stenosis is a complex condition to treat; however, vaginal reconstruction with a thigh flap can provide excellent cosmetic and functional results.

Robotic Female Pelvic Floor Reconstruction: A Review.

As the surgical correction of pelvic organ prolapse has continued to evolve, robotic-assisted abdominal sacrocolpopexy (RASC) has gained increasing popularity. Studies have shown equivalent subjective and objective outcomes compared with the "gold standard" abdominal sacrocolpopexy. Additionally, this approach is associated with a shorter hospital stay and less cost than the traditional open procedure. Although there is a learning curve associated with RASC, the basic principles of the procedure are the same. Herein, we discuss the robotic techniques for repair of pelvic organ prolapse as well as discuss the currently available literature regarding RASC.

Evaluation and Management of Pelvic Organ Prolapse in Elderly Women.

Pelvic organ prolapse is a common disease in elderly patients. The most important symptom is vaginal bulge (bulge sensation or the sensation of something coming down through the vaginal introitus). This symptom is not different than in the general population. Diagnosis can be confirmed using just vaginal examinations to identify the presence of protrusion beyond the hymen, and is not different than in the general population. Different treatment options are available, including observation, nonsurgical, and surgical techniques. Pessaries and colpocleisis are the treatment options used more often in elderly patients than in the general population.

Cancer-specific mortality following radical cystectomy for bladder cancer with lymph node involvement: impact of pathologic disease features and adjuvant chemotherapy.

PURPOSE: While lymph node involvement (LNI) has been associated with adverse outcomes following radical cystectomy (RC), clinicopathologic variables associated with survival continue to be defined. Therefore, we evaluated survival in patients with LNI to define factors associated with death from bladder cancer. METHODS: We reviewed our institutional registry of 2,462 patients who underwent RC for muscle-invasive urothelial cancer between 1980 and 2006 to identify 307 (12.5 %) patients with LNI. All pathologic specimens were re-reviewed by a single urologic pathologist. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. RESULTS: The median number of lymph nodes (LNs) removed among patients with LNI was 12 (IQR 7, 19), and the median number of positive LNs was 2 (IQR 1, 3). Median postoperative follow-up was 8.7 (IQR 5.9, 15.7) years, during which time 255 patients died, including 188 from bladder cancer. On multivariate analysis, advanced tumor stage (HR 1.95; p = 0.046), presence of four or more positive lymph nodes (HR 1.82; p = 0.0022), and the presence of extranodal extension (HR 1.65, p = 0.0012) were associated with a significantly increased risk of death from bladder cancer, while receipt of adjuvant chemotherapy (HR 0.72, p = 0.041) was associated with significantly decreased cancer-specific mortality. CONCLUSIONS: Advanced pathologic tumor stage and presence of extranodal extension are associated with an increased risk of death from bladder cancer. Receipt of adjuvant chemotherapy is associated with improved survival, supporting the need for prospective clinical trials to assess the role of multimodal therapy in these patients.

Risk of repeat anti-incontinence surgery following sling release: a review of 93 cases.

PURPOSE: Sling procedures are the most common surgery for stress urinary incontinence in women. Lower urinary tract symptoms are well documented complications of these procedures that develop in 5% to 20% of patients. A common treatment for postoperative urinary retention and bothersome obstructive voiding symptoms after anti-incontinence surgery is sling release. While previous studies indicated the risk of recurrent stress urinary incontinence after surgical release of slings, there is a paucity of data on how many patients require repeat anti-incontinence procedures. MATERIALS AND METHODS: After receiving institutional review board approval we retrospectively reviewed the records of 143 consecutive female sling release procedures performed by 2 subspecialized urologists at our clinic from January 2000 through August 2012. A total of 121 patients underwent documented followup at our clinic, of whom 93 were treated with sling release for obstruction or retention after sling placement. We identified the characteristics of this patient population, specifically the incidence of subsequent anti-incontinence procedures. RESULTS: Mean ± SD patient age was 58 ± 13.2 years and median patient followup after surgical sling release was 32 months (IQR 6, 67). Of the 93 patients 13 (14%) required a repeat anti-incontinence procedure after sling release at a median of 3 months. CONCLUSIONS: Sling release remains an important treatment option in patients with obstruction after anti-incontinence surgery. Only a small percent of patients require repeat anti-incontinence surgery for recurrent stress urinary incontinence.

Anatomic basis of radical cystectomy and orthotopic urinary diversion in female patients.

Long considered oncologically hazardous or functionally damaging, radical cystectomy with orthotopic urinary diversion is the accepted standard of care for invasive bladder cancer. A number of anatomical and clinical observations have come together to make orthotopic urinary diversion possible for female patients. Not only have these observations led to the development of an oncologically safe, low-pressure reservoir for urine, but also have improved the postoperative quality of life. Urethral sparing technique is safe for patients without bladder neck or trigonal tumors. Furthermore, improved understanding of the female urethral rhabdosphincter has decreased the likelihood of postoperative urinary incontinence. Finally, female sexual function may be preserved in patients who undergo preservation of the neurovascular tissue lateral to the vagina. These improvements have solidified orthotopic urinary diversion as the procedure of choice for selected female patients requiring radical cystectomy.