A Comparative Review of Oral Board Delivery Across Procedural Disciplines.

OBJECTIVE: Despite its ubiquity in the certification process among surgical specialties, there is little data regarding oral board delivery across various procedural fields. In this study we sought to determine the specifics of oral board exam administration across surgical disciplines with the goal of highlighting common practices, differences, and areas of innovation. This comparative analysis might further serve to identify unifying principles that undergird the oral board examination process across specialties. DESIGN: A standardized questionnaire was developed that included domains of exam structure/administration, content development, exam prerequisites, information about examiners, scoring, pass/failure rates, and emerging technologies. Between December 2022 and February 2023 structured interviews were conducted to discuss specifics of various oral board exams. Interview answers were compared between various specialties to extrapolate themes and to highlight innovative or emerging techniques among individual boards. SETTING: Interviews were conducted virtually. PARTICIPANTS: Executive members of 9 procedural medical boards including anesthesiology, neurosurgery, obstetrics, and gynecology, ophthalmology, orthopaedic surgery, otolaryngology-head and neck surgery, plastic surgery, general surgery, and urology RESULTS: Common themes include assessment of pre-, intra- and postoperative care; all testing involved candidate examination by multiple examiners and psychometricians were used by all organizations. Important differences included virtual versus in person administration (3 out of 9), inclusion and discussion of candidates' case logs as part of the exam (4 out of 9), formal assessment of professionalism (4 out of 9), and inclusion of an objective structured clinical examination (2 out of 9). CONCLUSIONS: While there are common themes and practices in the oral board delivery process between various surgical fields, and important differences continue to exist. Ongoing efforts to standardize exam administration and determine best practices are needed to ensure oral board exams continue to effectively establish that candidates meet the qualifications required for board certification.

Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

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.

The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons.

BACKGROUND: Two-thirds of surgeons report work-related musculoskeletal disorders (WRMD). There is limited data on WRMD symptoms experienced by pregnant surgeons. METHODS: We distributed an electronic survey via personal contacts to attending and trainee surgeons across six academic institutions to assess the impact of procedural activities and surgical ergonomics (SE) on WRMD symptoms during pregnancy. RESULTS: Fifty-three respondents were currently or had been pregnant while clinically active, representing 93 total pregnancies. 94.7% reported that symptoms were exacerbated by workplace activities during pregnancy and 13.2% took unplanned time off work as a result. Beyond 24 weeks of pregnancy, 89.2% of respondents continued to operate/perform procedures, 81.7% worked >24-h shifts and 69.9% performed repetitive lifting >50 pounds. No respondents were aware of any institutional pregnancy-specific SE policies. CONCLUSIONS: Procedural activities can exacerbate pain symptoms for the pregnant surgeon. SE best practices during pregnancy warrant further attention.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

Current exposure to Female Pelvic Medicine and Reconstructive Surgery faculty during urology residency.

INTRODUCTION: Contemporary US resident exposure to Female Pelvic Medicine and Reconstructive Surgery (FPMRS) faculty during urology residency is unknown. METHODS: Accredited US urology residencies were identified through the American Urological Association (AUA). Accredited, urology-based FPMRS fellowships were identified through the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The number of faculty and residency positions were obtained from program AUA profiles if they were last modified within the current application cycle; this information was obtained from program websites if AUA profiles were outdated. Data on faculty fellowship training was manually extracted from program websites. A quality control cross-check of program and faculty training characteristics was performed through direct communication with 5% of programs. RESULTS: Of 139 accredited residency programs assessed, 10.8% were affiliated with an accredited, urology-based FPMRS fellowship. In total, 29.5% of residency programs, representing 25% of US urology residents, had neither a FPMRS fellowship nor any FPMRS certified faculty. The national FPMRS faculty-to-resident ratio was 1:10.8, and 7.4% of faculty at all residency programs were FPMRS certified. In comparison, faculty-to-resident ratios for other subspecialties were: 1:4.7 for pediatrics, 1:3.6 for oncology, 1:5.9 for minimally invasive surgery/endourology, 1:14.2 for trauma/reconstruction, and 1:11.8 for andrology or male sexual/reproductive health. The FPMRS faculty-to-resident ratio was 1:5.1 in programs with a urology-based FPMRS fellowship compared with 1:13.4 in programs without a FPMRS fellowship. CONCLUSIONS: 30% of US urology residency programs lack FPMRS trained faculty. Even when FPMRS faculty are on staff, the field is often underrepresented relative to other urologic subspecialties. Further studies are required to ascertain if inadequate exposure to FPMRS cases and mentors during training contribute to the shortage of urology residents who choose to specialize in FPMRS. This link has important implications for the current shortage of FPMRS providers.

A population-based analysis of predictors of penile surgical intervention among inpatients with acute priapism.

While consensus exists regarding risk factors for priapism, predictors of operative intervention are less well established. We assessed patient and hospital-level predictors associated with penile surgical intervention (PSI) for patients admitted with acute priapism, as well as length of stay (LOS) and total hospital charges using the National Inpatient Sample (2010-2015). Inpatients with acute priapism were stratified by PSI, defined as penile shunts, incisions, and placement of penile prostheses, exclusive of irrigation procedures. Survey-weighted logistic regression models were utilized to assess predictors of PSI. Negative binomial regression and generalized linear models with logarithmic transformation were used to compare PSI to LOS and total hospital charges, respectively. Among 14,529 weighted hospitalizations, 4,953 underwent PSI. Non-Medicare insurances, substance abuse, and ≥3 Elixhauser comorbidities had increased odds of PSI. Conversely, Black patients, sickle cell disease, alcohol abuse, neurologic diseases, malignancies, and teaching hospitals had lower odds. PSI coincided with shorter median LOS (adjusted IRR: 0.62; p < 0.001) and lower ratio of the mean hospital charges (adjusted Ratio: 0.49; p < 0.001). Additional subgroup analysis revealed penile incisions and shunts primarily associated with reduced LOS (adjusted IRR: 0.66; p < 0.001) and total hospital charges (adjusted Ratio: 0.49; p < 0.001). Further work is required to understand predictors of poor outcomes in these populations.

Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis.

INTRODUCTION: Priapism is a urologic emergency that may require surgical intervention in cases refractory to supportive care. Exchange transfusion (ET) has been previously used to manage sickle cell disease (SCD), including in priapism; however, its utilization in the context of surgical intervention has not been well-established. AIM: To explore the utilization of ET, as well as other patient and hospital-level factors, associated with surgical intervention for SCD-induced priapism METHODS: Using the National Inpatient Sample (2010-2015), males diagnosed with SCD and priapism were stratified by need for surgical intervention. Survey-weighted regression models were used to analyze the association of ET to surgical intervention. Furthermore, negative binomial regression and generalized linear models with logarithmic transformation were used to compare ET vs surgery to length of hospital stay (LOS) and total hospital charges, respectively. MAIN OUTCOME MEASURES: Predictors of surgical intervention among patients with SCD-related priapism RESULTS: A weighted total of 8,087 hospitalizations were identified, with 1,782 (22%) receiving surgical intervention for priapism, 484 undergoing ET (6.0%), and 149 (1.8%) receiving combined therapy of both ET and surgery. On multivariable regression, pre-existing Elixhauser comorbidities (e.g. ≥2 Elixhauser: OR: 2.20; P < 0.001), other forms of insurance (OR: 2.12; P < 0.001), and ET (OR: 1.99; P = 0.009) had increased odds of undergoing surgical intervention. In contrast, Black race (OR: 0.45; P < 0.001) and other co-existing SCD complications (e.g. infectious complications OR: 0.52; P < 0.001) reduced such odds. Compared to supportive care alone, patients undergoing ET (adjusted IRR: 1.42; 95% CI: 1.10-1.83; P = 0.007) or combined therapy (adjusted IRR: 1.42; 95% CI: 111-1.82; P < 0.001) had a longer LOS vs. surgery alone (adjusted IRR: 0.85; 95% CI: 0.74-0.97; P = 0.017). Patients receiving ET (adjusted Ratio: 2.39; 95% CI: 1.52-3.76; P < 0.001) or combined therapy (adjusted Ratio: 4.42; 95% CI: 1.67-11.71; P = 0.003) had higher ratio of mean hospital charges compared with surgery alone (adjusted Ratio: 1.09; 95% CI: 0.69-1.72; P = 0.710). CONCLUSIONS: Numerous factors were associated with the need for surgical intervention, including the use of ET. Those receiving ET, as well as those with combined therapy, had a longer LOS and increased total hospital charges. Ha AS, Wallace BK, Miles C, et al. Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis. J Sex Med 2021;18:1788-1796.

A Novel Risk Prediction Model to Triage Difficult Urethral Catheterizations.

OBJECTIVE: To construct a risk prediction model to identify cases of difficult urethral catheterizations (DUC) in order to prevent complications from improper placement. MATERIALS AND METHODS: Using a single-institution database of urologic consults for Foley catheterizations from June 2016 to January 2020, a model to predict DUC in male patients was constructed. DUC was defined as requiring the use of a guidewire, cystoscopy, urethral dilation, and/or suprapubic tube (SPT) placement, while a simple Foley was defined as an uncomplicated placement of a regular or coudé catheter. A final model to predict DUC was constructed using multivariable logistic regression and internally validated using bootstrap statistics. RESULTS: A total of 841 consults were identified, with 181 (21.5%) classified as a DUC. On multivariable regression, patient-specific factors as overweight BMI (OR: 1.71; P = .014), urethral stricture disease (OR: 7.38; P < .001), BPH surgery (OR: 2.47; P < .001), radical prostatectomy (OR: 4.32; P = .001), and genitourinary (GU) prosthetic implants (OR: 3.44; P = .046) were associated with DUC. Situational factors such as blood at the meatus (OR: 2.40; P < .001), and consulting team (eg, surgery OR: 4.82; P < .001) were also significant. Bootstrap analysis of the final model demonstrated good overall accuracy (predictive accuracy: 75%). CONCLUSION: This model is a promising tool to help providers identify patients who likely require catheterization by a urologist and potentially reduce catheterization-related complications. The high rate of uncomplicated catheterizations also highlights the need for continuing education amongst healthcare professionals. External validation and application to the initial Foley encounter will shed light on its overall utility.

The National Resident Matching Program Code of Conduct: What Is the Perceived Degree of Compliance During the Urology Match Process?

OBJECTIVE: To assess the incidence of violations to the National Resident Matching Program Code of Conduct during the Urology Match. MATERIALS AND METHODS: We sent a survey to all 285 applicants to a single urologic program during 2017 Match cycle; the questions pertained to illegal interview questions, postinterview communication, second-look qualifications, and the applicant's perceived impact of these factors. RESULTS: At total of 166 responses were obtained (response rate 58%). Ninety-six (58%) applicants received follow-up communication from at least 1 program, the majority from multiple programs. Of those who received postinterview communication, 13% reported verbal communication, and 19% felt misled by communication to believe they had a higher chance of matching at a program. Fifty (30%) respondents did a second-look visit, and 44% reported feeling obligated to do so in order to match. Finally, 141 of 166 (85%) applicants reported being asked illegal questions regarding personal life, rank list, and/or other interviews. Female applicants reported being asked illegal questions significantly more frequently than male applicants (P < .01). CONCLUSION: During the 2017 Urology Match, a high proportion of applicants experienced violations of the National Resident Matching Program Code of Conduct. Violations included illegal questions, postinterview written and verbal communication, and pressure to do second-look visits. These findings corroborate numerous anecdotal reports, and may provide the groundwork to improve the fairness of the residency application process for the future.

Sling Procedures for the Treatment of Stress Urinary Incontinence: Comparison of National Practice Patterns between Urologists and Gynecologists.

PURPOSE: Sling procedures, which have become the dominant method of surgical management of stress urinary incontinence, are frequently performed by urologists and gynecologists. Few studies investigating trends in surgical management have focused on differences in provision of care between the specialties. In this study we compared national practice patterns of sling procedures by provider type. MATERIALS AND METHODS: We analyzed the 2006 to 2013 ACS (American College of Surgeons) NSQIP (National Surgical Quality Improvement Program) database. CPT-4 codes were used to identify patients who underwent sling procedures and any concomitant pelvic floor procedures. Patient and operative characteristics were compared between urologists and gynecologists using bivariate and multivariate analysis. RESULTS: Our analytical cohort included 22,192 sling procedures, of which 5,718 (25.8%) and 16,474 (74.2%) were performed by urologists and gynecologists, respectively. Urologists performed a greater percent of autologous fascial sling procedures than gynecologists (1.16% vs 0.06%, p <0.001). Concomitant prolapse repair was performed in 8,664 patients (44.1%), including 954 (16.7%) of urologists and 7,710 (46.8%) of gynecologists. On multivariable analysis urology patients were less likely to undergo concomitant prolapse repair or hysterectomy. Urology patients were more likely to have hypertension and be older, have a higher ASA® (American Society of Anesthesiologists®) class and be current smokers. CONCLUSIONS: Gynecologists perform the majority of sling procedures for stress urinary incontinence. While gynecologists perform more concomitant procedures, urologists tend to operate on older patients with more comorbidities. Urologists also perform a greater proportion of autologous fascial sling procedures. These findings demonstrate that, although gynecologists perform a greater number of surgeries, urologists treat a unique population of patients who require operative management of stress urinary incontinence.

The Timing of Radical Cystectomy for bacillus Calmette-Guérin Failure: Comparison of Outcomes and Risk Factors for Prognosis.

PURPOSE: We compared the pathological and survival outcomes of patients who underwent radical cystectomy soon after bacillus Calmette-Guérin failure with those of patients who received additional salvage intravesical chemotherapy before cystectomy for nonmuscle invasive bladder cancer. We also identified predictors of prognosis in the entire cohort. MATERIALS AND METHODS: We retrospectively analyzed the records of 117 patients who underwent radical cystectomy for recurrent nonmuscle invasive bladder cancer at our institution from 1990 to 2012. The cohort was divided into group 1 of 61 patients treated only with bacillus Calmette-Guérin with or without interferon-α and group 2 of 56 who received at least 1 additional salvage intravesical chemotherapy after bacillus Calmette-Guérin. RESULTS: Final pathology and survival outcomes did not differ significantly between the groups. Five-year overall and cancer specific survival was similar in groups 1 and 2 at 80% and 85%, respectively, at approximately equivalent followups. Median bladder retention was 1.7 years longer in group 2 (p <0.001). On multivariate Cox regression analysis delayed cystectomy in group 2 did not convey a significant hazard for all cause mortality after cystectomy (HR 1.08, p = 0.808). Only up-staging to cT1 (HR 1.88, p = 0.045), lymph node invasion (HR 2.58, p = 0.023) and prostatic urethra involvement (HR 1.95, p = 0.029) achieved significance. CONCLUSIONS: With appropriate selection for salvage intravesical chemotherapy patients who elect bladder sparing treatment instead of earlier radical cystectomy after bacillus Calmette-Guérin fails do not sacrifice positive pathological or oncologic outcomes while retaining bladder function for a significantly longer duration.

Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?

OBJECTIVE: To evaluate trends in male urethral and penis/incontinence case volumes among urology residents and assess these for adequate surgical training/competency. METHODS: Accreditation Council for Graduate Medical Education (ACGME) case logs of urology residents graduating from U.S. programs from 2009 to 2013 were reviewed to determine the surgical volume of select index categories. Male urethral cases encompass urethrectomy and urethroplasty, whereas male penis/incontinence cases include urethral slings and sphincters. Case volumes as "surgeon," "assistant," and "teaching assistant" were reviewed and compared to ACGME minimum requirements. RESULTS: A total of 1032 graduating residents reported case logs. For male urethral surgery, residents reported weighted averages (standard deviation [SD]) of 12.7 (9.0) cases as "surgeon," 1.5 (3.5) cases as "assistant," and 0.2 (1.0) as "teaching assistant." The minimum requirement for these cases is 5. The annual 10th percentiles as "surgeon" ranged from 4 to 5 cases throughout the study period. For male penis/incontinence cases, residents reported weighted averages (SD) of 45.5 (22.7) cases as "surgeon," 3.6 (5.5) cases as "assistant," and 1.5 (3.0) cases as "teaching assistant." The minimum requirement is 10 cases. The 10th percentiles as "surgeon" ranged from 19 to 23 cases. CONCLUSION: Although the majority of residents met the minimum standard for these cases, about 10% of residents did not meet the requirement for male urethral surgery. In addition, a review of learning curves for these procedures suggests that the ACGME minimum requirements may be insufficient to confer actual competency in skill. Increasing this number in training or specialized postgraduate training programs is needed to provide actual competency.

The da vinci robot system eliminates multispecialty surgical trainees' hand dominance in open and robotic surgical settings.

BACKGROUND AND OBJECTIVES: Handedness, or the inherent dominance of one hand's dexterity over the other's, is a factor in open surgery but has an unknown importance in robot-assisted surgery. We sought to examine whether the robotic surgery platform could eliminate the effect of inherent hand preference. METHODS: Residents from the Urology and Obstetrics/Gynecology departments were enrolled. Ambidextrous and left-handed subjects were excluded. After completing a questionnaire, subjects performed three tasks modified from the Fundamentals of Laparoscopic Surgery curriculum. Tasks were performed by hand and then with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, California). Participants were randomized to begin with using either the left or the right hand, and then switch. Left:right ratios were calculated from scores based on time to task completion. Linear regression analysis was used to determine the significance of the impact of surgical technique on hand dominance. RESULTS: Ten subjects were enrolled. The mean difference in raw score performance between the right and left hands was 12.5 seconds for open tasks and 8 seconds for robotic tasks (P<.05). Overall left-right ratios were found to be 1.45 versus 1.12 for the open and robot tasks, respectively (P<.05). Handedness significantly differed between robotic and open approaches for raw time scores (P<.0001) and left-right ratio (P=.03) when controlling for the prior tasks completed, starting hand, prior robotic experience, and comfort level. These findings remain to be validated in larger cohorts. CONCLUSION: The robotic technique reduces hand dominance in surgical trainees across all task domains. This finding contributes to the known advantages of robotic surgery.

Phase II trial of intravesical nanoparticle albumin bound paclitaxel for the treatment of nonmuscle invasive urothelial carcinoma of the bladder after bacillus Calmette-Guérin treatment failure.

PURPOSE: Response rates to current second line intravesical therapies for recurrent nonmuscle invasive bladder cancer range between 10% and 30%. Nanoparticle albumin bound (nab-)paclitaxel has increased solubility and lower toxicity compared to other taxanes. Results of the phase I intravesical trial of this compound demonstrated minimal toxicity during dose escalation. We now report the results of a phase II trial to assess efficacy. MATERIALS AND METHODS: This study was an investigator initiated, single center, single arm, phase II trial investigating the use of nab-paclitaxel in patients with recurrent Tis, T1 and Ta urothelial carcinoma in whom at least 1 prior regimen of intravesical bacillus Calmette-Guérin failed. Patients received 500 mg/100 ml nab-paclitaxel administered in 6 weekly intravesical instillations. Efficacy was evaluated with cystoscopy, biopsy, cytology and imaging. If complete response was achieved, patients were treated with full dose monthly maintenance treatments for 6 months. RESULTS: A total of 28 patients were enrolled in the study. Of these patients 10 (35.7%) exhibited a complete response after initial treatment. At 1 year all of these responses remained durable after maintenance therapy. At a mean followup of 21 months (range 5 to 47) 19 of 28 (67.8%) patients retained their bladders without progression or distant metastases. A single patient had progression to muscle invasive disease at radical cystectomy. Treatment related adverse events were noted in 9 of 28 (32.1%) patients and were limited to grade 1 or 2. CONCLUSIONS: Intravesical nab-paclitaxel has minimal toxicity and a 35.7% response rate in patients with nonmuscle invasive bladder cancer and previous bacillus Calmette-Guérin failure. Complete response remained durable at 1 year followup in this heavily pretreated patient population.

The role of preoperative prostatic urethral biopsy in clinical decision-making at the time of radical cystectomy.

INTRODUCTION: Involvement of the prostatic urethra by bladder cancer directly impacts prognosis, risk of urethral recurrence, and timing of radical cystectomy (RC); it also affects the type of urinary diversion chosen. Both cold cup biopsies and transurethral (TUR) loop biopsies have been used to evaluate the status of the prostatic urethra. We report our 20 year experience with preoperative and intro-operative prostatic urethral biopsies in order to determine relative efficacy and associated treatment implications. MATERIALS AND METHODS: The Columbia University urologic oncology database was reviewed and yielded 234 men who underwent preoperative endoscopic biopsies of the prostatic urethra before RC between 1990 and 2010. Two techniques were described: 1) cold cup biopsy, and 2) TUR loop biopsy. We evaluated the sensitivity, specificity, and predictive values for these respective techniques relative to the final pathological status of the prostatic urethra (PU) in the RC specimen. RESULTS: Of the 234 urethral biopsies 115 (49.1%) were cold cup and 96 (41.1%) were TUR loop biopsies. In the remaining 9.8% of patients, the technique could not be determined. Eighty-one preoperative biopsies (34.6%) revealed involvement of the urethra. No differences were observed in predictive values, sensitivity, and specificity between the two preoperative techniques. The negative predictive value (NPV) was higher than positive predictive value (PPV) for both preoperative approaches. Thirty-eight patients (16.2%) had a urethral frozen section analysis done intra-operatively. Only 1 patient (3%) had an abnormality on frozen section, being the negative predictive value (NPV) higher than the positive predictive value (PPV) for the test's ability to predict the status of the final urethral margin. Urethrectomy was performed at cystectomy in 52 patients with a positive biopsy; 15 (28.8%) of these patients ultimately had a negative PU on final pathology. Only 2/182 (1%) of the patients with an intact urethra presented with a urethral recurrence with a median follow up of 30.5 months. CONCLUSIONS: Preoperative prostatic urethral biopsy does not adequately predict final prostatic urethral status at radical cystectomy. No differences in predictive capacity could be detected with either cold cup biopsy or TUR biopsy. Intra-operative biopsy of the prostatic urethra is predictive of a negative urethral margin. Simultaneous radical urethrectomy should not be performed based up on preoperative prostatic urethral biopsy results alone.

The effect of fibrin clot inhibitors on the immunomodulatory efficacy of Bacillus Calmette-Guérin therapy for non-muscle-invasive bladder cancer.

OBJECTIVE: To determine if there is a difference in clinical outcomes among non-muscle-invasive bladder cancer patients taking fibrin clot-inhibiting (FCI) medications (aspirin, clopidogrel, or warfarin) while receiving Bacillus Calmette-Guérin (BCG) therapy compared with their counterparts not taking anticoagulation. MATERIALS AND METHODS: Our Investigational Review Board-approved database was queried for patients who received an induction course of BCG from 2001 to 2011. The analysis included 224 patients with a minimum of 3 months of follow-up. Recurrence-free survival (RFS), cystectomy-free survival, overall survival, and disease-specific survival were analyzed using the Kaplan-Meier method stratified by FCI status. Logistic regression was used to predict the initial response rate to BCG and progression by FCI status. RESULTS: Of the 224 patients analyzed, 68, 19, and 23 patients were taking aspirin, clopidogrel and warfarin, respectively, at BCG induction. No specific FCI was associated with differences in cystectomy-free survival, overall survival, disease-specific survival, or the likelihood of progression at recurrence. Neither warfarin nor clopidogrel affected RFS. Patients taking aspirin trended toward increased RFS, although this was not statistically significant (P = .058). Multivariate analysis showed aspirin use was associated with an increased initial response to BCG (odds ratio, 2.41; P = .031) CONCLUSION: Contrary to the postulated inhibitory molecular effect of FCI on BCG-binding activity, this study did not substantiate a significant impact on BCG efficacy of the concomitant use of these medications during BCG induction. The observation that aspirin use potentiates an increased initial response to BCG may warrant further analysis.

The effect of race and gender on the surgical management of the small renal mass.

BACKGROUND: To date, no population studies have been designed to assess the impact of race and gender on the rate of nephron-sparing surgery (NSS) across the United States. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients with T1a renal cell carcinoma (RCC) treated over the most recent decade, 1998-2007. Baseline socio-demographic data were compared between Caucasian and African-American patients using χ(2) and t-test analysis, and rates of radical nephrectomy (RN) were compared for all permutations of race and gender. A multivariate logistic regression model was in turn created with these variables to predict the odds of undergoing a radical nephrectomy. No prior assumptions were made regarding superiority of partial nephrectomy (PN) over RN as a therapeutic intervention. RESULTS: A total of 14,953 patients were eligible for inclusion in this study, and of these, 1,804 (12%) were African-American. Comparably, African-American patients were younger (<50 years; 23 vs. 28%, P < 0.001), and had an increased rate of high grade disease (13 vs. 16%, P < 0.001). Among different subsets of race and gender, African-American women received PN least often (28%) compared with all other groups, with African-American women at a 47% increased risk of undergoing RN compared with Caucasian male counterparts (95% CI: 1.24-1.73). CONCLUSIONS: Significant racial and gender disparities exist with regard to utilization of nephron-sparing surgery for small renal masses, particularly in African-American women. Further efforts should be directed to elucidating and addressing the rationale behind this disparity to ensure the uniformity of care.

The impact of perioperative blood transfusion on survival following radical cystectomy for urothelial carcinoma.

INTRODUCTION: Perioperative blood transfusion (PBT) has been shown to contribute to cancer progression and mortality. This study sought to determine the impact of PBT during radical cystectomy on cancer-specific survival (CSS) and overall survival (OS). MATERIALS AND METHODS: The Columbia University Urologic Oncology Database was reviewed for patients who underwent a RC from 1989 to 2010 (n = 638). PBT was defined as non-autologous packed red blood cells (PRBC) received during the same hospital stay as the radical cystectomy. Clinical and pathological variables were compared between the cohorts and survival analysis was performed with the Kaplan-Meier and Cox-regression methods. The primary outcomes were CSS and OS. RESULTS: Of 638 patients identified, 209 patients (32.8%) underwent PBT with an average of 2.21 ± 1.66 units transfused PRBC. Mean age was 68.1 ± 11.2 years; median follow up was 25.5 months (range 1-164 months). The number of units of PRBC transfused was inversely associated with OS (HR 1.12; p = 0.008) and CSS (HR 1.12; p = 0.049) on univariable analysis. Additionally, Kaplan-Meier analysis demonstrated a significant difference in OS (p = 0.0211) in patients who received more units of PRBC. However, on multivariable analysis, the number of units of PRBC transfused was not an independent predictor of outcome for CSS (p = 0.300) or OS (p = 0.246). CONCLUSIONS: Each additional unit of PRBC received during radical cystectomy is associated with a decrease in survival. However, after controlling for clinical and pathologic factors which predict survival, PBT does not have an independent affect upon CSS or OS.