Documenting Horizontal Integration Among Urologists Who Treat Prostate Cancer.

Relatively little is known about the extent and effects of horizontal mergers among physician specialists. We developed and implemented a methodology to document changes in physician practice structure resulting from horizontal integration among urology groups. We merged cancer registry records from four large states with Medicare Part B claims to identify all urologists who treated men with prostate cancer. We added information from SK & A surveys and extensive internet searches to assign a practice structure to each urologist-year (2005-2014). Horizontal integration among small urology groups led to a sharp increase in the proportion of urologists who belong to large urology practices with ownership in intensity modulated radiation therapy and/or anatomical pathology services. By 2014, more than half of New Jersey urologists and about 43% of urologists in Florida and Texas were members of such large practices, whereas small percentages (7%-16%) were employed by a health system. In contrast, more than 27% of California urologists were employed but only 17.5% had ownership in intensity modulated radiation therapy and/or pathology services. Importantly, we found our indicators of market share of urologists associated with each practice structure type were highly concordant with indicators of market share based on number of prostate cancer episodes treated by each practice structure type.

Telemedicine in Urogynecology.

Telemedicine, which provides safe, equitable, patient-centered care, has gained significant momentum in recent years. Success using telemedicine has been seen across diverse groups of patients for a variety of diagnoses, including older adults and gynecology patients. In response to the coronavirus disease 2019 pandemic, federal and local governments have issued provisions to improve reimbursement and accessibility to telemedicine. In urogynecology, virtual care is growing in popularity, along with a growing body of literature in support of this method of providing care. Providers should use clinical judgment and existing data to guide them on which clinical conditions are appropriate for virtual care.

Positive environmental impact of remote teleconsultation in urology during the COVID-19 pandemic in a highly populated area.

INTRODUCTION: Greenhouse gas (GHG) emissions are a serious environmental issue. The healthcare sector is an important emitter of GHGs. Our aim was to assess the environmental cost of teleconsultations in urology compared to face-to-face consultations. MATERIALS AND METHODS: Prospective study of all patients who had a remote teleconsultation over a 2-week period during COVID-19 pandemic. Main outcome was the reduction in CO2e emissions related to teleconsultation compared to face-to-face consultation and was calculated as: total teleconsultation CO2e emissions-total face-to-face consultation CO2e emissions. Secondary outcome measures were the reduction in travel distance and travel time related to teleconsultation. RESULTS: Eighty patients were included. Face-to-face consultations would have resulted in 6699km (4162 miles) of travel (83.7km (52 miles) per patient). Cars were the usual means of transport. CO2e avoided due to lack of travel was calculated at 1.1 tonnes. Teleconsultation was responsible for 1.1kg CO2e while face-to-face consultation emitted 0.5kg of CO2e. Overall, the total reduction in GHGs with teleconsultation was 1141kg CO2e, representing a 99% decrease in emissions. Total savings on transport were 974 € and savings on travel time were 112h (1.4h/patient). CONCLUSIONS: Teleconsultation reduces the environmental impact of face-to-face consultations. The use of teleconsultation in our urology departments resulted in the avoidance of more than 6000km of travel, equivalent to a reduction of 1.1 tonnes of CO2e. Teleconsultation should be considered for specific indications as the healthcare system attempts to become greener. LEVEL OF EVIDENCE: 3.

Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery?

The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.

Management of Patients Who Seek Urologic Care in Covid-19 Pandemic Era.

INTRODUCTION:  Novel coronavirus Disease (Covid-19) has emerged in Wuhan, China in December 2019 and became a pandemic in a few weeks. In this review, we aimed to summarize the current urologic practice trends worldwide to help urologist in decision making in disasters particularly in Covid-19 pandemic. MATERIAL AND METHOD:  We have performed a PubMed and Internet search by using the keywords: 'Covid', 'new coronavirus', 'coronavirus urology, 'covid urology' without a date restriction.  Results: All elective surgeries for benign urological conditions such as urinary tract stone disease that not caused complicated obstruction, benign prostate enlargement, infertility, incontinence and genitourinary prolapse, erectile dysfunction undescendent testis, vesico-ureteral reflux   should be postponed till the lasting of Covid-19 outbreak. In obstructing ureteral stone both nephrostomy tube and double-J stent insertion are valid management options. However, one must consider that these procedures must be performed under local anesthesia when possible to spare a ventilator. When deferring urooncological operations and treatments oncological outcomes must be considered. Aggressive cessation or reducing the dosage of immunosuppressant therapy might be an option in renal transplanted patients with severe pneumonia or acute respiratory distress syndrome.

Telemedicine and Smart Working: Recommendations of the European Association of Urology.

CONTEXT: Telemedicine provides remote clinical support using technological tools. It may facilitate health care delivery while reducing unnecessary visits to the clinic. The coronavirus disease 2019 (COVID-19) outbreak has caused an abrupt change in our daily urological practice, converting many of us to be reliant on telehealth. OBJECTIVE: To provide practical recommendations for effective use of technological tools in telemedicine. EVIDENCE ACQUISITION: A Medline-based and gray literature search was conducted through April 2020. We selected the most relevant articles related to "telemedicine" and "smart working" that could provide important information. EVIDENCE SYNTHESIS: Telemedicine refers to the use of electronic information and telecommunications tools to provide remote clinical health care support. Smart working is a model of work that uses new or existing technologies to improve performance. Telemedicine is becoming a useful invaluable tool during and even beyond the COVID-19 pandemic. It is time for us to formalize the place of telemedicine in routine urological practice, and it is our responsibility to adapt and learn about all the tools and possible strategies for their optimal implementation during the pandemic to ensure that the quality of care received by patients and the outcomes of patients and their families are of the highest standard. CONCLUSIONS: Telemedicine facilitates specialized urological clinical support at a distance, solves problems of limitations in mobility, reduces unnecessary visits to clinics, and is useful for reducing the risk of viral transmission in the current COVID-19 outbreak. Furthermore, both personal and societal considerations may favor continued use of telemedicine, even beyond the COVID-19 pandemic. PATIENT SUMMARY: Telemedicine in urology offers specialized remote clinical support to patients, similar to face-to-face visits. It is very useful for reducing unnecessary visits to the clinic, as well as reducing the risk of contagion in the current coronavirus disease 2019 (COVID-19) pandemic.

COVID-19 pandemic and uro-oncology follow-up: A "virtual" multidisciplinary team strategy and patients' satisfaction assessment.

COVID-19 pandemic strongly modified the organizations of our clinical practice. Strict containment measures have been adopted to limit the disease diffusion. In particular, hospital face-to-face post discharge and follow up visits have been reduced. Although cancelling or deferring appointments seems to be a pragmatic approach, this solution may have a devasting long-term impact on health medical care and on patients. In this context, telemedicine and remote consultations may have the potential to provide healthcare minimizing virus exposure. In this paper we describe how Multidisciplinary team (MDT) reorganized genitourinary cancer care delivery at our Institute (AO SS Antonio e Biagio e Cesare Arrigo, Alessandria), taking advantage of telematic means. Furthermore, we present our preliminary results regarding patients' satisfaction.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy. MATERIALS AND METHODS: A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes. RESULTS: Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05). CONCLUSION: In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Female Authorship Publishing Trends and Forecasting in Pediatric Urology: Are We Closer to Gender Equality?

OBJECTIVE: To review the literature of 5 pediatric urology topics and conduct gender based and forecasting analyses of first and corresponding authors. METHODS: A PubMed search was performed for hypospadias, hydronephrosis, vesicoureteral reflux, bladder and bowel dysfunction, and cryptorchidism over 3 decades from 1990 to 2019. The 50 most relevant "best match" papers from each decade were extracted by topic. Author gender, specialty, and advanced degrees, along with journal and publication variables were collected. Forecasting analyses were conducted through the Holt-Winters method. RESULTS: Among 750 papers analyzed, 78% of corresponding and 70% of first authors were male. A significant upward trend was observed for female-authored publications in both first and corresponding positions over time (P <.01). Forecasting analyses predicted a continuing upward trend for female corresponding (55%) and first authors (83%) by 2049. Most studies originated from pediatric urology (59%), followed by pediatric surgery (9%) and endocrinology/genetics (5%). Papers focused in The Journal of Urology (30%) with the majority originating from the United States (38%). Most were retrospective (44%) and discussed medical (54%) versus surgical management (20%). CONCLUSION: The majority of pediatric urology literature has been generated by male authors. A persistent, rising trend in female authorship across all examined pediatric urology topics was noted. These encouraging findings are projected to continue to increase in the future, suggesting a movement toward equal and fair gender representation in authorship in pediatric urology.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload in Urology.

OBJECTIVE: To define the relationship between urology relative value units (RVUs) and measures of surgical complexity and physician workload. Secondary objectives include: (1) identifying procedures with outlying RVU values for their measures of surgical complexity and workload; and (2) calculating projected RVU values for these procedures. METHODS: We obtained surgical case data for 71 urology current procedural terminology (CPT) codes from the 2017 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Pearson correlation coefficients were calculated to measure the association between mean total work RVU and operative time, length of hospital stay, serious adverse events, readmissions, and mortality. We developed a multivariable regression model to predict mean total work RVU from these measures. Studentized residuals were used to identify outlying CPT codes for both bivariable and multivariable regression models, and empirically derived RVU values from complexity and work effort metrics were estimated. RESULTS: We analyzed 71 urology CPT codes encompassing 55,068 cases. RVUs correlated well with median length of hospital stay (R = 0.81), median operative time (R = 0.92), serious adverse events (R = 0.83), and readmissions (R = 0.74). RVUs were poorly correlated with mortality (R = 0.34). Outlying procedures identified using the multivariable model were retroperitoneal lymph node dissection (projected +21.09 RVUs), laparoscopic ureteroneocystotomy (projected -12.34 RVUs), and cystectomy with bilateral pelvic lymphadenectomy (projected +9.37 RVUs). CONCLUSION: Urology work RVUs correlate more with operative time than other measures of surgical complexity and physician workload. There exist several significant outlying procedures for various work measures. Incorporating objective work data may improve RVU assignments in the future.

Impact of Three-dimensional Printing in Urology: State of the Art and Future Perspectives. A Systematic Review by ESUT-YAUWP Group.

CONTEXT: Three-dimensional (3D) printing has profoundly impacted biomedicine. It has been used to pattern cells; replicate tissues or full organs; create surgical replicas for planning, counseling, and training; and build medical device prototypes and prosthetics, and in numerous other applications. OBJECTIVE: To assess the impact of 3D printing for surgical planning, training and education, patient counseling, and costs in urology. EVIDENCE ACQUISITION: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. EVIDENCE SYNTHESIS: After screening, 4026 publications were identified for detailed review, of which 52 were included in the present systematic review: two papers reported the use of 3D-printing modeling for adrenal cancer, two papers for urethrovesical anastomosis, 24 papers for kidney transplantation and renal cancer, 13 papers for prostate cancer, seven papers for pelvicalyceal system procedures, and three papers for ureteral stents, and three papers reported 3D-printed biological scaffold development. CONCLUSIONS: Three-dimensional printing shows revolutionary potentials for patient counseling, pre- and intraoperative surgical planning, and education in urology. Together with the "patient-tailored" presurgical planning, it puts the basis for 3D-bioprinting technology. Although costs and "production times" remain the major concerns, this kind of technology may represent a step forward to meet patients' and surgeons' expectations. PATIENT SUMMARY: Three-dimensional printing has been used for several purposes to help the surgeon better understand anatomy, sharpen his/her skills, and guide the identification of lesions and their relationship with surrounding structures. It can be used for surgical planning, education, and patient counseling to improve the decision-making process.

Engaging telehealth to drive value-based urology.

PURPOSE OF REVIEW: Telehealth, or the remote delivery of healthcare services using telecommunications technology, has the potential to revolutionize the delivery of healthcare and contribute to ongoing efforts to provide high-value care. RECENT FINDINGS: We discuss several categories of telehealth that have been applied to healthcare. Several of these approaches, in particular video visits and teleconsultations, have promising early data demonstrating the significant benefits of telehealth technology with respect to the quality of care, access, cost savings, and patient experience. Nonetheless, considerable knowledge gaps still exist regarding how and for which patients and diseases telehealth modalities should be applied. Finally, we discuss the barriers to widespread adoption at the institutional, state, and federal levels. SUMMARY: Maximizing the value of healthcare is an important goal for hospitals, physicians, and policymakers. Telehealth leverages advances in technology and the widespread availability of telecommunications devices to make healthcare communication more available, more convenient, and more efficient for patients and providers. With appropriate policies and incentives, telehealth initiatives can improve the value of urologic care and smooth the transition to a value-based healthcare system.

Frailty and geriatric assessment in urologic oncology.

PURPOSE OF REVIEW: As the population ages, urologic oncologists are caring for older and more vulnerable patients that must withstand complex surgical treatments. Our healthcare environment emphasizes surgical quality, reductions in length of hospital stay, reduced readmission rates, and high patient satisfaction. So those who manage urologic malignancies must be able to optimize their patients. Understanding the concept of frailty, how to diagnose it in a timely and reliable manner, appreciate its perioperative impact, and consider interventions to reduce its effects may improve surgical outcomes. RECENT FINDINGS: There has been a recent swell of early research regarding frailty in urologic oncology and its related perioperative effects. Increasing degrees of frailty are associated with greater morbidity and mortality, and more adverse discharge disposition after surgical procedures. Clinicians are, thus, recognizing the value of geriatric assessment in their practice and exploring ways to integrate it using a team-based approach. Universal geriatric recommendations are now available in specific urologic populations to guide these efforts. Importantly, formal geriatric assessment outperforms physician discretion or the 'eyeball' test. SUMMARY: The current review offers a comprehensive study of the impact of frailty in urologic oncology, methods for its assessment, and active interventions to reduce it.

The 2017 Update of the German Clinical Guideline on Epidemiology, Diagnostics, Therapy, Prevention, and Management of Uncomplicated Urinary Tract Infections in Adult Patients. Part II: Therapy and Prevention.

BACKGROUND: We aimed to update the 2010 evidence- and consensus-based national clinical guideline on the diagnosis and management of uncomplicated urinary tract infections (UTIs) in adult patients. Results are published in 2 parts. Part 1 covers methods, the definition of patient groups, and diagnostics. This second publication focuses on treatment of acute episodes of cystitis and pyelonephritis as well as on prophylaxis of recurrent UTIs. MATERIALS AND METHODS: An interdisciplinary group consisting of 17 representatives of 12 medical societies and a patient representative was formed. Systematic literature searches were conducted in MEDLINE, EMBASE, and the Cochrane Library to identify literature published in 2010-2015. RESULTS: For the treatment of acute uncomplicated cystitis (AUC), fosfomycin-trometamol, nitrofurantoin, nitroxoline, pivmecillinam, and trimethoprim (depending on the local rate of resistance) are all equally recommended. Cotrimoxazole, fluoroquinolones, and cephalosporins are not recommended as antibiotics of first choice, for concern of an unfavorable impact on the microbiome. Mild to moderate uncomplicated pyelonephritis should be treated with oral cefpodoxime, ceftibuten, ciprofloxacin, or levofloxacin. For AUC with mild to moderate symptoms, instead of antibiotics symptomatic treatment alone may be considered depending on patient preference after discussing adverse events and outcomes. Primarily non-antibiotic options are recommended for prophylaxis of recurrent urinary tract infection. CONCLUSION: In accordance with the global antibiotic stewardship initiative and considering new insights in scientific research, we updated our German clinical UTI guideline to promote a responsible antibiotic use and to give clear hands-on recommendations for the diagnosis and management of UTIs in adults in Germany for healthcare providers and patients.

Cost and cost-effectiveness studies in urologic oncology using large administrative databases.

OBJECTIVE: Urologic cancers are not only among the most common types of cancers, but also among the most expensive cancers to treat in the United States. This study aimed to review the use of CEAs and other cost analyses in urologic oncology using large databases to better understand the value of management strategies of these cancers. METHODS: A literature review on CEAs and other cost analyses in urologic oncology using large databases. RESULTS: The options for and costs of diagnosing, treating, and following patients with urologic cancers can be expected to rise in the coming years. There are numerous opportunities in each urologic cancer to use CEAs to both lower costs and provide high-quality services. Improved cancer care must balance the integration of novelty with ensuring reasonable costs to patients and the health care system. CONCLUSION: With the increasing focus cost containment, appreciating the value of competing strategies in caring for our patients is pivotal. Leveraging methods such as CEAs and harnessing large databases may help evaluate the merit of established or emerging strategies.

Economy of Standards: European Association of Urology Guideline Changes Influence Treatment Costs in Stage I Testicular Cancer Patients.

OBJECTIVE: The study aimed to calculate direct medical costs (DMC) during the first year of diagnosis and to evaluate the impact of guideline changes on treatment costs in clinical stage (CS) I testicular germ cell tumor (TGCT) patients in a German healthcare system. MATERIALS AND METHODS: Healthcare expenditures as DMC during the first year of diagnosis for 307 TGCT patients in CS I treated at our institution from 1987 to 2013 were calculated from the statutory health insurance perspective using patient level data. Three periods were defined referring to the first European Association of Urology (EAU) guideline in 2001 as well as to subsequent major guideline changes in 2005 and 2010. Data source for cost calculations were the German Diagnosis Related Groups system for inpatient stays (version 2014) and the German system for reimbursement of outpatient care (EBM - Einheitlicher Bewertungsmaßstab, edition 2014). RESULTS: During our 25 years of study period, mean DMC in the first year after diagnosis for the entire cohort of TGCT patients in CS I almost halved from EUR 13.000 to EUR 6.900 (p < 0.001). From 1987 to 2001, DMC for CS I seminomatous germ cell tumor (SGCT) patients were EUR 13.790 ± 4.700. From 2002 to 2010, mean costs were EUR 10.900 ± 5.990, and from 2011 to 2013, mean costs were EUR 5.190 ± 3.700. For CS I non-seminomatous germ cell tumor (NSGCT) patients, from 1987 to 2001, mean DMC were EUR 11.650 ± 5.690. From 2002 to 2010, mean costs were EUR 11.230 ± 5.990, and from 2011 to 2013, mean costs were EUR 11.170 ± 7.390. Follow-up examinations became less frequent over time, which caused a significant cost reduction for NSGCT (p = 0.042) while costs remained stable for SGCT. When adding costs of relapse treatment, active surveillance (AS) was the most cost-effective adjuvant treatment option in CS I NSGCT whereas one course carboplatin or AS caused similar expenditures in SGCT patients. CONCLUSION: The introduction of the EAU guidelines in 2001 caused a decrease in DMC in CS I seminoma patients. This cost reduction mainly took place due to the declining importance of radiation therapy. No substantial changes were seen in patients with CS I NSGCT. Costs for follow-up care also diminished, but to a lesser degree. Even when considering expenditures for relapse treatment, AS remained cost-effective in CS I TCGT patients. Our data show that evidence-based medicine in TGCT can reduce DMC in the first year after diagnosis.